SANfTMIQ:M:;.HQR  MEDICAL 


UC-NRLF 


B   3   137  070 


Civil  Eng;ineering  Dept 


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UMIVERSITY  or  CALIFORNIA 
.£F,.KTrvTENT  O-    -IVIL  ENGINEERING 


UMIVERSITY  OF  CAI-IFORHIA 
DEPARTMENT  O^   -.WW.  ENGINEERIHS 

BERKELEY.  CALIFORNIA 


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MEDICAL  WAR  MANUAL  No.  1 

Authorized   by  the  Secretary  of  Wa^ 

ind   under  the  Supervision   of  the  Surgeon-General 

and  the  Council  of  National   Defense 


Sanitation  for  Medical 

Officers 


BY 

EDWARD  B.  VEDDER,  M.D. 

COLONEL,  MEDICAL    CORPS,  U.  S.  A. 

SECOND  EDITION,   THOROUGHLY  REVISED. 


TlUusttateD 


LEA    &    FEBIGER 

PHILADELPHIA    AND    NEW    YORK 

1918 


i 


PREFACE  TO  THE  FIRST  EDITION. 


This  work  was  created  to  supply  in  a  compact  form  that 
can  be  conveniently  carried  in  the  pocket  of  a  uniform,  such 
data  as  may  be  useful  to  medical  officers  as  a  guide  for  sani- 
tary work.  As  far  as  possible  the  information  has  been  made 
official  by  the  inclusion  of  the  sanitary  orders  and  circulars 
bearing  on  the  topics  discussed.  All  notes  have  been  made 
as  brief  and  concise  as  possible.  An  endeavor  has  been  made 
in  writing  the  section  on  transmissible  diseases  to  present  the 
most  recent  knowledge  concerning  the  etiology  and  trans- 
mission of  the  disease  in  question,  together  with  all  informa- 
tion necessary  upon  which  to  base  a  sanitary  campaign  for 
its  control. 

It  is  needless  to  state  that  no  originahty  is  claimed  for  the 

material  presented,  which  is  in  the  nature  of  a  compilation 

derived  from  many  sources.    Special  acknowledgment  should 

be  made  to  Havard's  Military  Hygiene,  Melville's  Military 

Hygiene   and  Sanitation,   and   Lelean's  Sanitation  in  War 

as  works  from  which  I  have  borrowed  largely. 

E.  B.  V. 


(IV) 


CONTENTS. 


The  Camp 7 

The  March 79 

Embarkation 95 

Trenches  and  the  Battlefield 98 

Insects  Concerned  in  the  Transmission  of  Disease  116 

Notes  on  Transmissible  Diseases      .....  152 


(V) 


SANITATION  FOR  MEDICAL  OFFICERS, 


THE  CAMP.i 


THE  RECRUIT. 

The  most  important  factor  in  securing  the  physical 
efficiency  of  the  soldier  is  the  proper  selection  of  the  recruit. 
The  subject  is  dealt  with  in  all  works  on  military  hygiene, 
and  specific  instructions  for  the  physical  examination  and 
selection  of  recruits  will  be  issued  by  the  War  Department 
from  time  to  time.  At  present  these  orders  are  changing  so 
rapidly  that  it  is  not  advisable  to  include  them  in  this  book. 

Measures  to  Correct  Defects. — In  times  of  peace  an 
effort  is  made  to  accept  only  men  without  physical  defects. 
In  time  of  war  many  men  will  necessarily  be  accepted  as  fit 
for  service  but  who  have  minor  defects  that  can  be  corrected. 
But  some  system  should  be  employed,  otherwise  these  defects 
will  not  be  corrected,  and  the  man  will  subsequently  become 
a  burden  to  the  command  while  on  active  service.  If  the 
following  form  is  filled  out  at  the  time  the  physical  exami- 
nation is  made,  the  camp  surgeon  could  keep  a  file  of  these 
cards  and  defects  could  be  corrected  systematically  during 
the  period  of  training.  Thus  a  list  of  the  men  needing  dental 
treatment  could  be  made  out  and  these  men  ordered  to  report 
to  the  dentist. 

^See  F.  S.  R.,  1914,  232-245. 


8  SANITA'TION  FOR   MEDICAL  OFFICERS 

1.  Conformation.         Weight,         Height,         Pignet's    index. 

2.  Skin:     Normal?  Diseased? 

3.  Muscles:     Well  developed?      Moderately  developed?      Flabby? 

4.  Bones  and  Joints:     Normal?  Diseased? 

5.  Teeth:     In  good  repair?     Repairs  necessary?     Urgent  repairs? 

6.  Feet:     Corns?     Hallux  valgus?     Weak  arches?     Other  defects? 

7.  Circulation:     Pulse?         Blood-pressure?         Any    defects? 

8.  Respiratory   system:     Any   defects? 

9.  Genito-urinary :     History  of  infection?     Wassermann?     Urine? 

Defects? 

10.  Gastro-intestinal :     Constipation?  Other  defects? 

11.  Nervous  system: 

12.  Eye,  ear,  nose  and  throat:     Defects. 

13.  Other  diseases  or  defects? 

14.  Cleanliness? 

15.  Habits:     Tobacco         alcohol         sexual         dietary         sleep 

16.  Endurance? 

17.  Fit  for  field  service? 

18.  Corrective  measures? 

Until  some  such  plan  is  adopted  it  would  be  advisable  for 
the  camp  surgeon  to  direct  that  a  physical  examination  be 
made  and  the  form  filled  out  in  the  case  of  all  men  who  pre- 
sent themselves  on  sick  report  for  any  cause,  and  that  the 
corrective  measures  indicated  as  necessary  should  be  system- 
atically applied. 

Malingering. — While  in  time  of  peace  malingering  is  very 
rare,  medical  officers  may  expect  to  meet  with  a  certain 
percentage  of  malingerers  among  those  who  wish  to  escape 
military  service  in  time  of  war.  Sometimes  it  will  be  neces- 
sary to  determine  whether  a  man  is  a  malingerer  or  is  suffer- 
ing from  hysteria  or  neurasthenia.  Hysteric  and  neuras- 
thenic men  are  best  excluded  from  military  service,  but  effort 
must  be  made  to  detect  malingerers.  This  is  usually  easy 
when  a  patient  can  be  observed  over  a  considerable  period, 
but  may  be  very  difficult  at  a  single  examination.  Malin- 
gering is  detected  in  several  ways. 

I.  Few  people  know  the  symptoms  or  signs  of  any  infirmity 
well  enough  to  feign  it  successfully,  and  if  the  examining 


THE   CAMP  9 

physician  is  thoroughly  posted  on  the  symptomatology  of 
the  condition  being  simulated,  he  can  usually  detect  dis- 
crepancies. 

2.  The  use  of  methods  to  put  the  patient  off  his  guard 
and  to  watch  him  when  he  beheves  he  is  alone. 

3 .  The  Psychology  of  the  Malingerer. — He  is  apt  to  be  unduly 
voluble  in  presenting  his  symptoms,  or  may  be  unduly 
reticent,  and  his  language  and  actions  are  often  inconsistent. 

4.  Suggestion. — If  it  is  suggested  that  a  certain  symptom 
is  usually  present  in  the  condition  complained  of,  a  malin- 
gerer will  frequently  produce  the  symptom  even  though  it 
may  be  ridiculous. 

5.  Special  Tests. — It  would  be  impossible  to  cover  the  sub- 
ject of  malingering  within  the  Umits  of  these  notes,  but  a 
few  simple  tests  for  the  disabilities  commonly  feigned  may 
be  useful  to  medical  officers. 

Cardiac  and  circulatory  lesions  may  be  feigned  by  taking 
various  drugs  just  before  the  examination.  Tobacco  has 
been  swallowed.  In  the  British  service,  cordite  has  been 
chewed.  When  anything  of  this  kind  is  suspected,  the  man 
should  be  placed  in  hospital  under  observation  and  examined 
unexpectedly. 

Urine. — Sugar  and  albumin  have  been  placed  in  samples 
of  urine.  Sometimes  cane-sugar  is  used,  which  is  never  found 
in  urine.  If  glucose  is  used,  too  much  is  commonly  added, 
and  the  amount  varies  considerably  at  different  times. 
Make  the  patient  urinate  in  the  presence  of  the  examiner. 

Epilepsy. — Epilepsy  is  often  claimed  to  exist.  If  malin- 
gering is  suspected,  as  it  may  be  if  too  many  claiming  epi- 
lepsy present  themselves,  the  man  may  be  accepted  and 
placed  under  observation.  The  malingerer  seldom  attempts 
a  fit  in  the  presence  of  a  medical  officer.  Soap  may  be 
chewed  to  produce  a  foam.  The  true  epileptic  is  always 
unconscious  in  a  fit.     This  may  be  tested  by  touching  an 


I 


10  SANITATION  FOR   MEDICAL   OFFICERS 

eye  to  determine  the  presence  of  the  conjunctival  reflex,  or 
by  pressure  over  the  supra-orbital  notch. 

Bed-wetting. — This  is  a  bar  to  enlistment  for  obvious 
reasons.  Yet  frequently  men  who  wish  to  avoid  miUtary 
service  will  claim  to  be  bed-wetters  and  will  persistently 
live  up  to  the  claim.  The  percentage  of  adult  bed-wTtters 
is  almost  infinitesimal,  and  malingering  is  to  be  suspected  j 
should  two  or  more  cases  occur  at  about  the  same  time.  The  " 
remedy  is  to  place  a  night  man  on  duty  to  wake  the  suspect 
every  hour  to  make  him  urinate.  If  a  malingerer  he  will 
usually  give  up  after  several  such  nights. 

The  Eye. — Every  man  knows  that  eyesight  is  essential  in 
the  military  service  and  that  visual  defects  may  reUeve  him 
of  irksome  duty.  It  is  imperative  to  distinguish  between 
actuality  and  pretence.  The  most  common  form  of  malin- 
gering is  a  statement  that  one  eye  is  imperfect,  and  the  man 
pleading  this  disabiUty  may  either  pretend  to  have  the 
defect,  or  may  actually  have  a  defect  and  trade  upon  it. 
Each  such  case  must  be  regarded  as  genuine  until  proved 
otherwise.  Take  the  vision  for  distance,  and  with  the  oph- 
thalmoscope the  state  of  cornea,  iris,  lens  and  vitreous 
should  be  noted.  The  malingerer  may  resist  this  examination 
by  winking  or  other  means.  The  retina  is  examined  and  the 
refractive  index  estimated.  When  a  defect  is  claimed  that 
cannot  be  accounted  for  objectively,  it  is  to  be  suspected. 
Take  the  trial  frame  and  place  a  blank  opposite  the  good  eye 
and  a  plus  3  or  4  before  the  eye  to  be  tested.  Then  add  minus 
glasses  until  the  frame  for  the  eye  to  be  tested  contains  minus 
glasses  enough  to  exactly  neutralize  the  previous  plus  glass. 
In  a  majority  of  cases  this  will  be  successful,  for  if  any  im- 
provement is  admitted,  the  man  is  a  malingerer.  The  man 
may  read  the  letters  with  his  lips  while  claiming  not  to  see 
them.  Be  on  guard  against  pupils  artificially  dilated  with 
atropine  or  cocain. 

Complete  blindness  is  seldom  alleged,  but  alleged  bUndness 


THE   CAMP  11 

of  one  eye  is  common.  The  pupil  of  a  blind  eye  cannot  be 
made  to  contract  to  the  smallest  degree  by  even  a  strong  light. 
Be  sure  mydriatics  have  not  been  used.  The  pupil  of  a  blind 
eye  is  generally  dilated  and  a  blind  eye  generally  deviates 
when  the  sound  eye  is  fixed.  Take  the  trial  frame.  Opposite 
the  good  eye  place  a  plus  1 2  lens.  This  puts  it  out  of  action. 
A  plain  glass  is  then  put  in  front  of  the  alleged  bUnd  eye, 
and  print  of  a  large  size  is  suddenly  placed  before  him.  If 
he  reads  test  types  of  any  size,  the  deception  is  proved.  A 
prism  base  downward  may  be  placed  before  the  good  eye 
while  the  man  looks  at  a  distant  candle.  If  he  sees  two 
candles,  binocular  vision  is  proved. 

Color-blindness  is  not  a  bar  to  enlistment  for  the  line. 

Tests  for  Hearing. — Absolute  deafness  is  seldom  feigned, 
but  deafness  of  one  ear  is  often  claimed.  Pretended  deafness 
is  not  always  easy  to  detect.  A  man  who  is  deaf  and  wishes 
to  hear  involuntanly  turns  his  head  to  the  speaker.  If  the 
patient  does  not  do  this,  or  only  at  times,  he  should  be 
suspected.  Examine  the  meatus  by  reflected  light,  mean- 
while assuming  the  deafness  for  granted.  If  wax  is  present, 
remove  it.    See  if  the  tympanum  is  normal. 

There  are  two  kinds  of  deafness:  (i)  When  the  sound- 
conducting  apparatus  (tympanum  and  ossicles)  are  damaged. 
(2)  Nerve-deafness,  the  result  of  derangement  of  the  internal 
ear.  Normally  when  a  tuning-fork  is  made  to  vibrate  and 
held, opposite  the  outer  canal,  it  is  heard  for  a  longer  period 
than  if  the  base  is  applied  to  the  bone  behind  the  ear.  If  the 
sound-conducting  apparatus  is  damaged,  the  tuning-fork 
when  placed  against  the  skull  will  be  heard  for  a  longer  time 
than  when  it  is  placed  opposite  the  external  ear.  Should  the 
tympanum  and  ossicles  be  wholly  destroyed,  the  tuning-fork 
will  not  be  heard  at  the  external  ear,  but  wall  still  be  heard 
when  placed  on  the  skull,  for  sound  still  reaches  the  nerve 
through  the  bones  of  the  skull.    In  nerve-deafness  if  a  tuning- 


12  SANITATION   FOR   MEDICAL   OFFICERS 

fork  is  applied  to  the  bone  behind  the  ear,  the  vibrations  are 
not  heard  as  long  as  when  it  is  applied  outside  the  meatus. 

Tests. — If  when  the  sound  ear  is  apparently  closed  with  the 
hand,  but  lea\dng  a  chink  between  the  fingers,  and  the  patient 
states  that  he  hears  nothing,  there  is  sufficient  evidence  of 
malingering.    Assuming  that  the  deafness  is  alleged  in  the 
left  ear,  a  tuning-fork  is  placed  behind  the  left  ear  and  the 
right  ear  closed.     Even  though  the  left  ear  is  completely 
deaf,  the  vibrations  will  be  conducted  by  bone  to  the  sound  ■ 
ear  and  be  heard,  but  a  malingerer  will  often  deny  all  knowl-  I 
edge  of  the  sound.    The  patient  may  be  blindfolded,  and  a  1 
watch  held  at  varying  distances  and  the  results  recorded.    If 
malingering  is  attempted,  it  is  impossible  for  accuracy  to  be 
maintained,  and  the  results  often  vary  so  that  detection  is 
easy.    Thus  the  patient  may  state  that  he  does  not  hear  it 
at  one  foot  when  he  says  he  does  hear  it  at  three  feet. 

Fain  in  the  Back. — This  is  frequently  alleged  as  a  cause  of 
disabiUty.  When  pain  exists  in  the  spine,  stiffness  and 
rigidity  naturally  follow.  If  there  is  no  stiffness  and  no 
rigidity,  it  is  reasonable  to  suppose  that  there  is  no  actual 
disease  of  the  spine. 

Lumbago. — Lumbago  is  bilateral,  widespread,  relieved 
by  pressure  and  mostly  experienced  when  making  certain 
movements. 

Injury. — The  usual  injury  is  a  tearing  of  the  fibers  of 
some  of  the  lumbosacral  muscles.  It  is  almost  invariably 
unilateral. 

When  a  man  is  suspected,  blindfold  him  and  ask  him  to 
point  out  the  painful  spot.  Mark  it  with  a  blue  pencil  and 
after  further  examination  repeat.  If  the  pain  is  assumed  he 
may  point  to  a  spot  several  inches  from  the  first  one.  When 
his  attention  is  diverted  to-  the  sound  side,  considerable  pres- 
sure may  be  appUed  to  the  affected  side  without  eliciting 
evidence  of  pain.  If  a  man  has  pain  in  the  upper  part  of  the 
back,  this  can  generally  be  elicited  by  bending  the  head  for- 


THE   CAMP  13 

ward  while  the  trunk  is  held  rigid,  thus  stretching  the 
vertebral  muscles.  If  this  can  be  done  without  pain,  it  is 
probable  the  alleged  pain  does  not  exist.  If  the  patient 
claims  he  cannot  bend  his  back,  let  him  suppose  he  is  not 
watched  and  notice,  how  he  puts  on  his  shoes. 

The  Nervous  System. — When  disease  of  the  nervous  system 
is  claimed,  a  comprehensive  examination  will  usually  estab- 
lish the  truth  or  falsity  of  the  claim. 

Pupil  Reflex. — Eliminate  disease  of  the  eye  and  the  effect 
of  drugs  that  may  be  taken  for  the  purpose  of  deception  and 
test  eye  for: 

1.  Loss  of  light  reflex  alone,  i.  e.,  the  Argyll-Robertson 
pupil;  this  is  usually  found  in  tabes  dorsahs  and  paresis. 

2.  Loss  of  contraction  of  pupil  during  accommodation  and 
also  of  light  reflex;  usually  in  tabes  dorsalis. 

3.  Loss  of  all  pupil  reflexes;  commonly  due  to  syphiHs. 

4.  Inequality  of  pupils.  Tabes,  paresis,  aortic  aneurysm 
and  other  conditions. 

Knee-jerk. — This  may  be  simulated  or  exaggerated.  Make 
patient  close  both  eyes  and  distract  attention  before  making 
the  test. 

Babinski  Reflex. — Extension  instead  of  flexion  of  great  toe 
when  sole  is  tickled.  If  persistent  in  an  adult  it  indicates 
an  organic  lesion. 

Ankle-clonus. — True  ankle-clonus  is  difficult  to  feign  and 
should  be  accompanied  by  the  Babinski  reflex.  Test  for 
instability.    Romberg's  sign. 

Pain. — When  feigning  pain,  malingerers  may  shrink  before 
being  touched,  and  complain  bitterly  before  they  can  have 
been  hurt.  Blindfold  and  make  patient  locate  pain  with 
the  finger;  often  he  cannot  touch  the  same  spot  twice.  Is 
there  an  interval  between  the  movement  alleged  to  be  painful 
and  the  expression  of  pain?  The  two  are  instantaneous  if  pain 
is  real.  Objective  symptoms  of  pain  are  flushing  or  pallor  of 
face,  dilatation  of  pupil  and  increased  rapidity  of  the  pulse. 


4 


14  SANITATION  FOR  MEDICAL  OFFICERS 

Areas  of  Anesthesia. — Bandage  the  eyes  and  map  out  with 
a  pin  and  colored  pencil  the  alleged  anesthetic  area,  and  repeat 
the  procedure  several  times,  when  if  a  maUngerer,  the  area 
will  be  found  to  vary. 

Vaccination  against  Smallpox  and  Typhoid  Fever. — 
After  a  recruit  has  been  accepted  the  next  duty  of  the  medical 
officer  will  be  to  vaccinate  him  in  accordance  with  existing 
orders  which  follow.  Here  it  will  be  found  that  system 
is  indispensable  in  vaccinating  large  numbers  of  men.  The 
men  should  be  lined  up  by  companies  with  the  left  arm 
bared.  A  number  of  men  should  assist  in  the  operation.  One 
man  washes  the  arm,  another  paints  a  small  spot  with  tinc- 
ture of  iodine  to  sterilize  the  skin  for  the  typhoid  inoculation 
and  the  recruit  then  passes  to  the  surgeon,  who  gives  him  his 
injection.  He  then  passes  to  another  surgeon  who  vaccinates 
him  against  smallpox  and  then  passes  to  a  clerk  who  makes 
out  his  record.  The  surgeon  who  gives  the  typhoid  should 
have  a  small  instrument  boiler  with  a  number  of  hypodermic 
needles,  and  as  soon  as  one  injection  is  given,  the  needle  is 
dropped  into  the  boiler  and  a  clean  needle  that  has  been 
boiled  is  selected  for  the  next  man.  By  using  some  such 
system,  a  very  large  number  of  men  can  be  vaccinated  against 
both  typhoid  and  smallpox  in  one  day.  Major  E.  C.  Dalton 
has  devised  a  syringe  with  a  reservoir  holding  2oc.c.,so  that 
twenty  injections  can  be  given  with  a  single  filling. 

G.  O.  No.  30,  W.  D.,  Washington,  April  21,  1914.  Vacci- 
nation being  recognized  as  an  effective  means  of  preventing 
smallpox,  all  recruits  upon  enlistment  and  all  soldiers  upon 
reenlistment  will  be  vaccinated.  When  the  first  vaccination 
of  a  recruit  is  non-effective,  it  will  be  repeated  at  the  end  of 
eight  (8)  days. 

All  the  personnel  of  a  military  command,  station  or  trans- 
port, including  civilians  connected  therewith,  will  be  vacci- 
nated when  in  the  opinion  of  the  surgeon  responsible  for 
proper  sanitation  it  is  necessary  as  a  means  of  protection 


THE  CAMP  15 

against  smallpox.  Civilians  refusing  to  be  vaccinated  when 
so  directed  by  proper  authority  may  be  excluded  from  the 
military  reservation  or  station. 

Officers  should  be  vaccinated  at  least  once  in  a  period  of 
seven  years.  Troops  under  orders  to  perform  oversea  jour- 
neys or  field  service  will  be  inspected  by  a  surgeon  with 
respect  to  their  protection  against  smallpox,  and  those  who  in 
the  opinion  of  the  surgeon  require  it  -^ill  be  vaccinated. 

Bulletin  No.  30,  W.  D.,  Washington,  July  15,  1914.  In 
carrying  out  the  requirements  of  Paragraph  II,  General 
Orders,  No.  30,  War  Department,  1914,  all  vaccinations 
will  be  preceded  by  cleansing  of  the  site,  preferably  the 
brachial  insertion  of  the  deltoid,  with  water  and  alcohol. 

The  skin  at  selected  site  must  be  clean ;  antiseptics  are  not 
necessarily  employed;  should  they  be  used  they  must  be 
washed  away  with  sterile  water  that  the  activity  of  the  virus 
be  not  destroyed.  Wasliing  with  warm  water,  followed  by 
alcohol,  is  usually  sufficient,  the  alcohol  being  permitted  to 
evaporate  before  proceeding.  Scrubbing  with  soap  and  water 
is  necessary  for  a  dirty  skin,  but  needless  irritation  of  the  skin 
is  to  be  avoided. 

The  procedure  described  as  follows  is  preferable  to 
''scarification,"  which  will  no  longer  be  used: 

Incision  is  the  method  of  choice  and  it  should  be  made  with 
the  point  of  a  sterile  needle,  producing  a  "  scratch. "  A  sterile 
scalpel  may  be  used,  but  is  more  likely  to  cause  bleeding. 
The  incision  or  scratch  should  preferably  not  draw  blood. 
There  should  be  at  least  two  incisions,  three-quarters  of  an 
inch  long  and  one  inch  apart ;  after  exposure  to  smallpox  four 
incisions  will  be  made.  The  virus  is  then  placed  upon  the 
abraded  surface  and  gently  rubbed  in,  unnecessary  irritation 
being  avoided. 

The  wound  is  allowed  to  dry  thoroughly  and  can  be  left 
without  dressing,  though  several  layers  of  gauze  may  be 


16  SANITATION  FOR  MEDICAL  OFFICERS 

applied  with  adhesive  plaster.  Any  dressing  that  retains 
heat  and  moisture  is  bad.    Shields  will  no  longer  be  issued. 

Bathing  is  permitted,  but  unnecessary  use  of  the  limb  is  to 
be  discouraged  when  practicable. 

A  simple,  rapid  and  efficient  method  of  vaccination  which 
will  probably  be  recommended  in  future  orders  is  as  follows: 

1 .  The  arm  is  washed  with  warm  water,  alcohol  and  ether 
and  allowed  to  dry  thoroughly. 

2.  Three  drops  of  glycerinized  vaccine  are  expressed  from 
the  capillar}^  container  and  placed  on  the  arm  in  the  form  of 
an  equilateral  triangle  with  two-inch  sides. 

3.  From  six  to  ten  intracutaneous  punctures  are  then  made 
through  each  drop  with  a  sterile  needle,  holding  the  needle 
as  nearly  parallel  to  the  skin  as  possible  and  taking  care  not 
to  draw  blood.  The  skin  of  the  arm  is  held  taut  during  the 
time  of  puncture. 

The  needle  should  be  sharp,  and  should  enter  the  skin  at 
as  small  an  angle  as  possible.  This  method  gives  a  much 
higher  percentage  of  takes  than  the  usual  method  of  incision, 
there  is  less  liability  to  intercurrent  infection,  no  time  is  lost 
waiting  for  the  virus  to  dry  and  no  dressing  is  required. 

G.  O.  No.  4,  W.  D.,  Washington,  January  20,  1915.  Para- 
graph II,  G.  O.  No.  76,  W.  D.,  191 1,  as  amended  by  G.  O. 
No.  134,  W.  D.,  191 1,  is  rescinded  and  the  following  substi- 
tuted therefor: 

All  persons  entering  the  military  service  will  be  immu- 
nized against  typhoid  fever,  under  the  direction  of  a  medical 
officer,  as  soon  as  practicable  after  entrance.  Exception  may 
be  made  in  the  case  of  persons  over  45  years  of  age,  and 
when  the  occurrence  of  a  previous  attack  of  t^^Dhoid  fever 
or  a  complete  course  of  immunization  within  three  years  is 
established  to  the  satisfaction  of  the  responsible  medical 
officer. 

Cadets  at  West  Point  will  be  immunized  on  entering  the 
Academy. 


THE  CAMP  17 

Officers  under  45  years  of  age  yAW  be  reimmunized  after 
five  years,  and  enlisted  men  on  the  first  reenlistment  follow- 
ing the  original  administration.    Except  when  directed  by  the 
War  Department,  only  two  complete  courses  of  immuniza- 
tion will  be  required  during  service  in  the  Army. 

Reimmunization  will  consist  of  a  series  of  three  injections 
given  exactly  as  in  the  first  series. 

Recruits  will  be  immunized  at  places  of  enlistment,  unless, 
because  of  special  assignment  or  other  reason,  the  men  are 
not  to  remain  at  the  station  long  enough  to  allow  the  com- 
pletion of  the  course,  in  which  event  the  immunization  will 
be  completed  immediately  after  they  join  the  organizations 
or  stations  to  which  they  are  assigned.  On  the  descriptive 
and  assignment  card  of  every  recruit  or  reenlisted  man  will 
be  noted  "Typhoid  and  paratyphoid  immunization  com- 
pleted. ..  .(Date).  ...  "  or  "Typhoid  immunization  not 
administered,"  as  the  case  may  be.  In  the  latter  case  com- 
pany and  detachment  commanders  ^ill  see  that  the  immuni- 
zation is  begun  immediately  after  the  men  join  the  organiza- 
tions or  stations  to  which  assigned.  In  every  case  in  which 
immunization  has  been  completed,  the  remark,  "Typhoid 

immunization  completed.  .  .  .   (Date) ,"  will  be  entered 

on  the  soldier's  descriptive  list. 

Ci\^ian  employees  who  are  subject  to  field  service  of  any 
kind,  including  those  on  transports  and  in  the  mine  planter 
service,  will  be  immunized  as  soon  as  employed.  Officers 
under  whom  such  employees  are  working  will  enforce  this 
order. 

The  t\^hoid  prophylactic  to  be  used  is  manufactured 
exclusively  at  the  Army  Medical  School,  Washington,  D.  C, 
and  detailed  directions  for  its  use  are  given  in  circulars  from 
the  Surgeon  General's  Office. 

Records  will  be  kept  at  the  hospital  of  all  officers,  soldiers, 
and  ci\dUans  in  the  military  service  who  receive  the  anti- 
typhoid prophylactic^  giving  the  dates  of  immunization. 
2 


18  SANITATION  FOR  MEDICAL  OFFICERS 

Circular  No.  i6,  W.  D.,  Office  of  the  Surgeon-General, 
Washington,  March  20,  191 6.  I.  The  following  directions 
for  vaccination  against  typhoid  fever  and  for  keeping  the 
necessary  records  are  pubhshed  for  the  iniormation  of  medical 
officers. 

The  first  dose  is  J  c.c.  (7^  m.) ;  the  second  and  third  are  each 
I  c.c.  (15  m.).  An  interval  of  at  least  seven  days  should  elapse 
between  doses.  This  interval  may  be  extended  to  the  four- 
teenth day  in  case  of  necessity. 

The  site  of  the  inoculation  is  the  arm  at  the  insertion  of  the 
deltoid  muscle.  If  for  any  reason  this  site  cannot  be  used,  the 
needle  may  be  introduced  in  the  back,  over  the  lower  portion 
of  the  scapula,  or  in  the  chest  below  the  clavicle.  The  dose 
is  to  be  given  suhcutaneously  and  not  in  the  muscles  nor  into 
the  skin.  The  arm  should  be  cleansed  as  for  any  other 
operation.  Tincture  of  iodine  painted  over  the  dry  skin, 
before  and  after  the  injection,  has  proved  satisfactory. 

The  ampule  should  be  washed  off  in  an  antiseptic  solution 
and  opened  after  making  one  or  more  cuts  near  the  top  with 
a  file.  The  vaccine  can  be  drawn  out  of  the  container  with  a 
syringe,  or  it  may  be  emptied  into  a  shallow  glass  dish,  such 
as  a  salt  cellar,  vv^hich  has  been  sterilized  by  boiling. 

The  syringe  and  needle  should  be  steriUzed  by  boiling  in  2 
per  cent,  soda  solution.  To  insure  perfect  sterilization,  draw 
the  piston  out  to  its  full  length,  or  remove  it  entirely,  so  that 
the  barrel  is  full  of  w^ater  during  the  boiUng.  A  fresh  needle 
should  be  used  for  each  man,  or,  if  one  needle  must  be  used  on 
two  or  more  men,  it  should  be  resteriUzed  before  each  injection. 

No  person  should  be  vaccinated  who  is  not  perfectly  healthy 
and  free  from  fever.  The  temperature  will  be  taken  before 
vaccination  is  begun,  and  in  doubtful  cases  the  urine  should 
be  examined;  if  fever  or  any  other  symptoms  of  illness  are 
present,  the  procedure  should  be  postponed.  This  precaution 
is  necessary  to  avoid  vaccinating  men  who  may  be  in  the 
incubation  stage  of  ty^)hoid  or  other  fever.    Neither  beer  nor 


THE  CAMP  19 

alcohol  in  any  other  form  should  be  drunk  on  the  day  of  treat- 
ment. Vaccination  is  well  borne  by  children  and  by  women, 
using  doses  proportionate  to  the  body  weight,  taking  150 
pounds  as  the  unit.  Women  should  not  be  given  the  first  dose 
during  or  near  the  time  of  the  menstrual  period. 

The  most  suitable  time  for  the  administration  is  about  4 
o'clock  in  the  afternoon,  as  the  greater  part  of  the  reaction  is 
then  over  before  morning.  There  is  usually  som.e  headache 
and  malaise,  and  a  local  reaction  consisting  of  a  red  and  tender 
area  about  the  size  of  the  palm  of  the  hand,  and  sometimes 
tenderness  in  the  axillary  glands.  It  is  best  not  to  require  any 
duty  for  twenty-four  hours,  not  to  permit  active  exercise, 
such  as  long  rides  or  walks.  Rarely  marked  general  reactions 
occur — headache,  backache,  nausea,  vomiting,  herpes  labialis, 
occasionally  albuminuria,  and  some  loss  of  body  weight.  The 
number  of  such  reactions  is  exceedingly  small,  and,  regardless 
of  their  severity,  they,  as  a  rule,  disappear  inside  of  forty- 
eight  hours. 

The  Widal  reaction  is  positive  after  typhoid  vaccination, 
appearing  in  about  ten  days  after  the  first  dose,  and  it  remains 
positive  for  six  months  to  a  year.  This  fact  must  be  con- 
sidered in  diagnosing  typhoid  in  vaccinated  persons.  They 
may  give  a  positive  Widal  regardless  of  the  nature  of  the 
illness,  and  the  reaction  is  consequently  of  no  assistance  in 
diagnosis. 

If  typhoid  or  paratyphoid  fever  be  suspected,  the  diagnosis 
must  therefore  be  confirmed  by  blood  culture,  made  during 
WiQ  first  week  of  the  disease;  this  culture  will  be  sent  to  the 
Army  Medical  School  or  to  one  of  the  department  laboratories. 
Bottles  of  bile  medium  for  this  purpose  may  be  obtained  of  the 
Armv  Medical  School,  Washington,  D.  C;  the  department 
laboratory.  Fort  Leavenworth,  Kan.;  the  commanding 
officer,  Letterman  General  Hospital,  Presidio  of  San  Fran- 
cisco, Cal.;  the  department  laboratory.  Southern  Depart- 
ment,   San    Antonio,   Tex.;    the    department    laboratory. 


20  SANITATION  FOR  MEDICAL  OFFICERS 

Hawaiian  Department,  Honolulu,  H.  T.;  or  the  laboratory, 
Ancon  Hospital,  C.  Z.  Two  bottles  of  bile  medium  will  be 
kept  on  hand  at  all  hospitals.  A  subculture  from  any  positive 
blood  culture  will  be  sent  to  the  laboratory.  Army  Medical 
School,  for  confirmation  and  record. 

A  complete  record  will  be  kept  on  a  Vaccination  Register 
(Form  8i)  for  each  person  vaccinated,  showing  the  name, 
organization,  date  of  each  dose  of  vaccine  given,  and  a  record 
of  the  temperature  taken  immediately  before  giving  the  first 
dose  of  vaccine.  On  completion  of  the  vaccination,  a  state- 
ment to  that  effect,  giving  the  date,  name,  rank,  and  organiza- 
tion, will  be  sent  to  the  commanding  officer  of  the  organiza- 
tion to  which  the  man  belongs,  that  the  proper  notation 
may  be  made  on  the  descriptive  and  assignment  card  of  every 
recruit. 

In  every  case  of  typhoid  or  paratyphoid  fever,  or  suspected 
case  of  these  diseases,  occurring  in  an  officer  or  enhsted  man,  a 
statement  will  be  made  on  the  register  card  (Form  52),  show- 
ing the  number  of  doses  of  vaccine  given  and  the  date  of  the 
last  one.  If  the  patient  has  not  been  vaccinated  against 
typhoid  fever  a  notation  to  that  effect,  stating  the  reason  or 
other  circum.stances  learned,  will  be  entered  on  the  register 
card.  A  report  will  be  furnished  in  every  case  of  typhoid  and 
paratyphoid  fever  occurring  in  an  officer  or  enlisted  man  or  a 
civihan  employee  who  has  been  vaccinated,  describing  in 
detail  the  method  of  arriving  at  the  diagnosis  as  soon  as  it  is 
made.    This  report  will  follow  the  form  required  by  this  office. 

The  vaccine  should  be  stored  in  an  ice-box.  It  will  keep  for 
four  months  and  perhaps  longer  w^hen  stored  at  low  tempera- 
tures in  the  dark. 

A  fresh  ampule  should  be  opened  for  each  day's  use.  Any 
vaccine  remaining  unused  in  an  opened  ampule  at  the  end  of 
the  day  should  be  thrown  away.  The  only  typhoid  vaccine 
used  will  be  that  obtained  from  the  Army  Medical  School, 
and  will  be  furnished  on  request  by  information  slip  or  by 


THE  CAMP  21 

telegram  to  the  commandant.  When  for  any  reason  a  larger 
stock  is  on  hand  than  appears  to  be  needed,  directions  as  to 
its  disposition  will  be  obtained  from  the  commandant,  Army 
Medical  School,  upon  application  to  him  direct,  stating  date 
of  receipt  of  the  vaccine.  Stock  over  four  months  old  will  be 
destroyed  when  a  new  supply  has  been  received. 

II.  Circular  No.  15,  W.  D.,  Surgeon-General's  Office, 
December  29,  19 14,  is  hereby  superseded. 

G.  O.  68,  June  i,  1917,  W.  D.  I. — In  addition  to  vaccina- 
tion against  typhoid  fever  prescribed  in  Circular  16,  W.  D., 
Office  of  Surgeon- General,  19 16,  all  officers  and  enlisted  men 
of  the  U.  S.  Army  and  all  other  persons  associated  with  the 
military  forces  of  the  United  States  designated  for  service 
overseas  will  be  completely  vaccinated  against  paratyphoid 
fevers  ("A"  and  "B")  prior  to  their  arrival  in  Europe. 

Vaccination  against  paratyphoid  fever  will  be  given  in  same 
manner,  in  same  dosage  and  with  same  intervals  as  now 
prescribed  in  Sec.  I,  G.  O.  4,  W.  D.,  191 5,  as  amended  by 
Sec.  IV,  G.  O.  23,  W.  D.,  1915  (par.  273,  C.  of  O.,  1881- 
19 1 5),  for  vaccination  against  typhoid  fever.  The  only 
vaccine  used  for  this  purpose  will  be  the  mixed  "A"  and 
"B"  vaccine,  prepared  in  laboratories  of  the  Army  Medical 
School,  Washington,  which  can  be  had  upon  direct  applica- 
tion to  the  commandant  of  the  school. 

This  order  will  be  strictly  enforced. 

LiPOVACCiNES. — It  has  been  found  expedient  to  substitute 
oil  for  salt  solution  as  the  menstruum  for  bacterial  vaccines. 
By  using  an  oil  vaccine  it  is  possible  to  give  sufficient  vaccine 
at  a  single  dose  to  immunize  the  individual,  and  both  the 
local  and  systemic  reactions  are  less  severe,  since  oil  is 
absorbed  more  slowly  than  salt  solution.  Moreover,  the 
lipovaccines  can  be  kept  longer  without  deterioration.  These 
considerations  all  have  an  important  military  bearing.  The 
administration  of  the  entire  immunizing  dose  at  one  injection 
is  an  advantage  in  relieving  the  medical  service  from  a  con- 


22  SANITATION  FOR  MEDICAL  OFFICERS 

siderable  routine  of  injections  and  record  work  and  in  reliev- 
ing the  men  from  recurrent  annoyance  and  interference  with 
military  duties.  These  vaccines  have  been  thoroughly  tested 
and  have  been  officially  adopted  for  issue.  They  are  all  made 
at  the  Army  Medical  School. 

Typhoid  Paratyphoid  Vaccine. — The  old  salt  solution  vac- 
cine required  three  injections  of  2^  c.c,  thus  giving  a  total 
of  6250  million  organisms.  With  the  lipovaccine  in  a  single 
injection  of  i  c.c.  more  than  10,000  million  organisms  are 
given  of  typhoid,  paratyphoid  A  and  paratyphoid  B  in  equal 
amounts. 

Cholera,  dysentery,  plague,  pneumococcus,  meningococcus 
and  streptococcus  vaccines  have  also  been  prepared.  The 
first  three  may  be  used  should  our  troops  be  sent  where  these 
diseases  are  endemic.  The  pneumococcus  vaccine  will  be 
introduced  this  fall  (19 18)  for  voluntary  use,  and  all  medical 
officers  are  directed  to  obtain  volunteers  to  take  this  vaccine 
for  the  purpose  of  preventing  the  spread  of  pneumonia  during 
the  winter  months  and  to  secure  statistics  concerning  the 
results  following  its  use. 

Method  of  Administration  of  Lipovaccines. — The  skin 
should  be  sterilized  with  iodine.  The  vaccine  should  be 
warmed  to  37°  C.  to  facilitate  the  ready  flow  of  the  oil. 
Draw  up  the  oil  into  the  barrel  of  the  syringe  with  the  needle 
detached.  A  single  dose  of  i  c.c.  is  sufficient.  It  is  especially 
important  that  this  vaccine  be  given  siihcutaneously  and 
not  intravenously,  intramuscularly  or  under  the  fascia.  In 
order  to  ensure  this,  pick  up  a  fold  of  skin  and  inject  into  the 
subcutaneous  tissue  of  that  fold.  Practically  all  of  the  severe 
reactions  that  have  been  reported  have  been  due  to  the  neglect 
of  this  precaution.  Deep  injection  may  lead  to  fat  embolism 
and  defeats  the  object  of  this  inoculation.  The  precautions 
to  be  taken  regarding  absence  of  temperature  or  disease  are 
the  same  as  are  given  for  typhoid  vaccine  in  Circular  No.  16. 
It  is  advisable  to  give  the  vaccine  about  four  o'clock  in  the 


THE  CAMP  23 

afternoon,  and  the  man  should  be  required  to  remain  in 
quarters  for  twenty-four  hours  after  the  injection. 

The  record  of  vaccination  should  be  kept  on  form  8i,  that 
form  being  modified  by  writing  " Lipo  "  after  "Triple  vaccine," 
and  by  striking  out  "First"  in  the  dose  column,  and  by 
striking  out  all  columns  in  "second"  and  "third"  doses. 
The  batch  number  of  vaccine  used  should  always  be  entered 
on  the  card. 

N.  B. — On  standing  in  the  cold  some  of  the  fats  of  the 
vaccine  may  separate  and  cause  a  precipitate.  This  will 
disappear  on  standing  a  short  time  at  room  temperature. 

THE  SANITARY  SURVEY  OF  CAMP  SITES. 

The  senior  medical  ofhcer  on  duty  with  any  detachment  in 
the  field  will  make  a  sanitary  survey  of  the  area  covered. 
When  practicable,  this  survey  will  be  made  prior  to  occu- 
pancy of  the  ground  by  the  detachment.  The  survey  should 
cover  the  following  points: 

Camp  Site. — i.  Locate  on  map  those  actually  occupied, 
and  such  other  areas  as  offer  special  facilities. 

2.  Study  and  describe  these  sites  with  reference  to  terrain, 
area,  soil,  drainage,  proximity  to  roads,  water  supply,  shelter, 
possible  methods  for  disposal  of  wastes,  etc. 

3.  Under  war  conditions,  consider  the  shelter  afforded  by 
the  terrain  for  first-aid  stations  and  field  hospitals,  as  well  as 
availability  of  water,  fuel,  shelter,  etc. 

4.  Consider  the  facilities  and  means  for  evacuation  of  sick 
and  wounded,  including  nearness  to  railroad,  and  condition 
of  roads.  If  several  routes  are  available,  determine  which 
is  most  suitable. 

Water  Supply. — i.  Locate  on  map  and  note  the  source, 
distance  from  camp,  potability  and  quantity  available. 

2.  If  a  stream,  consider  the  possibility  of  contamination 
above  intake.  This  is  always  possible  if  it  flows  through  an 
inhabited  district. 


24  SANITATION  FOR  MEDICAL  OFFICERS 

3.  Steps  recommended  to  ensure  its  continued  purity, 
including  precautions  to  be  taken  to  prevent  its  fouling  by 
the  command  in  case  other  troops  are  encamped  below  the 
intake. 

4.  If  the  water  is  not  considered  safe,  outline  the  means  to 
be  taken  to  make  it  safe. 

Food  Supply. — i.  What  food  and  forage  can  be  obtained 
from  the  inhabitants  of  the  surrounding  country? 

2.  Make  all  necessary  recommendations  as  to  the  conserva- 
tion  and  preparation  of  this  food  supply  from  a  sanitary 
stand-point. 

Health  Conditions  of  Surrounding  Population. — i. 
Investigate  the  sanitary  condition  of  all  places  through  which 
troops  pass  or  in  which  they  halt.  Investigate  particularly 
the  presence  of  infectious  disease  among  the  inhabitants. 

2.  If  disease  be  present  and  a  halt  must  be  made,  outline 
the  precautions  that  must  be  taken  to  avoid  infection  of 
troops. 

Insects. — i.  Investigate  carefully  for  the  existence  and 
prevalence  of  flies  and  mosquitoes.  What  disposition  do  the 
inhabitants  make  of  their  manure.  If  there  is  any  accumu- 
lation of  manure,  it  may  be  assumed  that  there  will  be 
many  flies  in  warm  weather. 

2.  Outline  measures  to  be  taken  to  abate  these  nuisances: 
(i)  By  the  command.    (2)  By  the  inhabitants. 

Weather  Conditions.^i.  Investigate  the  daily  and 
seasonal  variation  in  temperature,  the  usual  amount  of  rain- 
fall, prevailing  winds  and  other  weather  conditions  that  may 
affect  the  health  of  the  command,  and  make  appropriate 
recommendations. 

SANITARY  ORDERS. 

Medical  officers  should  be  prepared  to  write  a  compre- 
hensive but  clear  and  concise  sanitary  order  should  they  be 
called  upon  to  do  so.    Such  an  order  should  first  outline  the 


THE  CAMP  25 

sanitary  duties  and  responsibilities  of  the  various  members^ 
of  the  command,  including  the  Chief  Surgeon,  Sanitary 
Inspectors  and  Regimental  Surgeons.  The  order  should  then 
proceed  to  give  expHcit  directions  wdth  regard  to  the  rani- 
tation  of  the  camp.  As  conditions  vary,  no  set  of  directions 
will  be  suitable  for  all  times  and  places,  but  such  an  order 
should  include  directions  with  regard  to  the  Water,  Disposal 
of  Excreta  and  Kitchen'  Wastes,  Disposal  of  Manure,  and 
instructions  for  Venereal  Prophylaxis,  with  such  other  sub- 
jects as  the  time  and  place  may  call  for.  The  following 
is  suggested  as  a  model  upon  which  such  orders  may  be 
dra\Mi. 

G.  O.  No.  —  Headquarters  Maneuver  Division, 

Plattsburg,  N.  Y., 
April  6,  1910. 

The  following  regulations  for  camp  sanitation  are  published 
for  the  information  and  guidance  of  all  concerned: 

1.  Responsibility  for  Sanitation. — Commanders  of  all 
grades  are  responsible  for  police  and  sanitation  and  for  the 
enforcement  of  the  provisions  of  these  regulations  within 
their  organizations. 

2.  Division  Surgeon. — ^The  division  surgeon  is  charged, 
under  the  commanding  general,  with  the  general  conduct 
and  supervision  of  the  Medical  Department  of  the  division 
in  the  performance  of  its  duties  and  will  make  recommenda- 
tion concerning  all  matters  pertaining  to  the  sanitary  welfare 
of  the  command. 

3.  Sanitary  Inspector. — The  sanitary  inspector  is  assistant 
to  the  division  surgeon  and  is  charged  especially  with  the 
supervision  of  the  sanitation  of  the  command  to  which  he  is 
assigned.  It  is  the  duty  of  organization  commanders  to 
remedy  defects  reported  to  them  with  the  least  possible 
delay. 


26  SANITATION  FOR  MEDICAL  OFFICERS 

4.  Sanitary  Squads. — Sanitary  squads  will  be  organized 
oy  the  division  surgeon  for  special  sanitary  purposes  such  as 
the  purification  of  water  supplies,  mosquito  and  fly  preven- 
tion, disposal  of  wastes  and  disinfection.  They  will  consist 
of  officers,  non-commissioned  officers  and  privates,  first  class, 
or  privates  of  the  Medical  Department,  assisted  by  civilian 
sanitary  laborers  employed  by  the  Quartermaster  Corps, 
and  when  necessary,  by  details  of  officers  and  enlisted  men 
from  other  branches  of  the  service. 

5.  Regimental  Surgeons. — The  senior  medical  officer  on 
duty  with  a  regiment  or  separate  unit  will  inspect  his  camps 
once  daily  and  oftener  if  necessary,  at  which  time  the  several 
organization  commanders  will  be  present  during  the  inspec- 
tion of  their  respective  commands  if  practicable.  All  sanitary 
defects  with  proper  recommendations  to  remedy  the  same 
will  be  reported  to  them,  and  they  will  immediately  take  the 
necessary  steps  to  correct  the  defects,  if  within  their 
authority.  If  such  is  not  feasible,  or  is  impracticable,  they 
will  immediately  forward  a  report  on  the  same,  for  the  action 
of  the  higher  authority. 

6.  General  Police. — At  all  inspections  special  attention 
will  be  given  to  the  condition  of  the  grounds,  tents,  kitchens, 
food,  bathing  faciUties,  and  latrines.  The  interior  of  the  tents 
must  be  kept  clean,  and  the  clothing,  blankets  and  bedding 
should  be  exposed  to  the  sunlight  daily,  weather  permitting. 
Tents  will  be  raised  during  the  daytime  in  good  weather,  and 
will  be  adequately  ventilated  at  night.  All  tents  will  be  furled 
and  struck  occasionally. 

7.  Kitchens. — All  food  and  water  in  camp  will  be  protected 
from  dust,  flies  and  sun.  An  eating  place  will  be  designated 
for  each  company,  and  men  will  not  be  allowed  to  take  food 
into  their  tents.  Eating  utensils  will  be  thoroughly  cleaned 
immediately  after  using.  Garbage  will  not  be  allowed  to 
accumulate  about  the  kitchen,  but  will  be  promptly  destroyed 
in  kitchen  crematories.    In  all  cases  all  kitchen  refuse  should 


THE  CAMP  27 

be  thrown  on  the  incinerator  at  once  in  order  to  avoid  attract- 
ing flies.  Do  not  throvv^  any  water  from  the  kitchen,  including 
that  used  forwashing,  cooking  or  eating  utensils,  on  the  ground. 
This  is  strictly  prohibited.  The  use  of  garbage  cans  will  not 
be  permitted;  they  attract  flies.  Water  barrels  or  cans  for 
drinking  water  will  be  kept  securely  covered  and  set  upon 
a  framework  so  that  the  faucets  will  be  3  feet  from  the 
ground.  Water  will  be  taken  from  the  barrels  or  cans  in  no 
other  way  than  by  drawing  it  from  the  faucets. 

8.  Water  Supply. — The  camp  water  supply  is  pure  and 
wholesome,  and  no  sterilization  of  drinking  water  is  necessary 
(should  this  not  be  the  case  the  statement  should  read: 
''  The  water  supply  is  impure  and  must  be  sterilized  before  use. 
Minute  directions  for  sterilization  should  then  be  given). 
Precautions  must  be  taken  to  prevent  subsequent  contami- 
nation, by  keeping  all  containers  scrupulously  clean  and 
protected  from  dust  and  other  sources  of  infection.  (In 
some  cases  it  may  be  necessary  to  place  a  guard  over  the 
water  supply,  and  in  these  cases  the  sanitary  order  must  be 
formed  to  suit  conditions.) 

9.  Disposal  of  Excreta  and  Wastes. — Organization  com- 
manders \^dll  be  held  responsible  for  the  police  of  their  respec- 
tive camps.  Each  company  or  similar  organization  will 
construct  incinerators  or  crematories  as  prescribed  in  Sec. 
216,  F.  S.  R.,  1 9 13,  for  the  disposal  of  all  solid  and  liquid 
garbage  of  the  organization,  and  no  other  disposition  will 
be  made  of  such  wastes.  Human  excreta  will  be  disposed  of 
in  pits  covered  by  latrine  boxes  unless  other  provision  has 
been  made.  Two  urinal  cans  will  be  placed  in  each  company 
street  at  night.  Latrine  pits  will  be  burned  out,  and 
seats  scrubbed  daily,  using  crude  oil  and  straw  or  other 
material.  Urinal  cans  will  be  burnt  out  daily,  and  the 
bottoms  covered  with  milk  of  lime  before  using.  Defilement 
of  ground  in  and  about  camps  is  absolutely  prohibited. 
Manure  will  be  hauled  to  a  designated  dumping  ground,  and 
there  burned  with  the  aid  of  crude  oil.    Rock  pit  crematories 

A 


28  SANITATION  FOR  MEDICAL  OFFICERS 

will  be  used  for  the  disposal  of  general  wastes  of  camp  areas 
not  under  the  jurisdiction  of  commanding  officers. 

lo.  Latrines  will  be  constructed  at  the  rate  of  one  for 
each  company,  one  for  the  officers  of  each  regiment  and  one 
for  Brigade  Headquarters.  The  pit  shall  be  3  feet  wide, 
8  feet  long,  and  8  feet  deep,  and  the  excavated  dirt 
shall  be  removed  at  least  4  feet  from  the  pit.  The  latrine 
box  must  be  fly-proof,  4  feet  wude,  9  feet  long,  and  18  inches 
high,  with  sides  sloping  outward  to  prevent  soiling.  The  top 
will  have  suitable  holes  at  intervals  of  2  feet  from  center, 
each  to  be  provided  with  a  cover  strongly  hinged.  Through 
the  center  of  the  cover  will  be  placed  6-inch  strips  and  stop 
blocks  to  prevent  the  covers  from  being  raised  so  far  that 
they  will  not  fall  back  into  position  of  their  own  weight. 
(For  construction  of  latrine  box  see  blue  print  furnished  by 
Quartermaster  Corps,  one  of  which  will  be  on  file  at  office 
of  Camp  Quartermaster.)  Toilet  paper  wnll  be  furnished 
and  must  be  kept  from  blowing  about  or  lying  on  the  ground. 
A  lantern  will  be  kept  burning  in  each  latrine  during  the  hours 
of  darkness. 

II.  Picket  Lines. — Picket  lines  and  places  where  horses  are 
tied  shall  be  kept  thoroughly  cleaned.  In  addition  to  careful 
raking  of  manure,  the  ground  at  each  picket  line  wdll  be  swept 
with  suitable  brooms  at  least  three  times  a  day,  and  the 
manure  piled.  The  manure  shall  be  removed  at  least  once  a 
day.  All  picket  fines  will  be  burnt  off  by  the  use  of  hay  and 
crude  oil  at  least  once  every  ten  days. 

12.  Food  and  Drinks. — No  food,  drinks,  or  like  commodities 
will  be  sold  in  camp  except  in  the  authorized  exchanges. 

13.  Personal  Cleanliness. — Each  soldier  must  bathe  at 
least  twice  weekly.  Men  must  wash  their  hands  thoroughly 
after  leaving  the  latrine,  and  before  each  meal.  Bath  houses 
must  be  kept  clean  and  inviting,  and  the  water  drained  prop- 
erly both  inside  and  outside. 

14.  Venereal  Inspections. — Venereal  inspections  will  be 
held  once  each  week,  at  which  time  all  enlisted  men  of  the 


THE  CAMP  29 

command  must  be  inspected.  At  these  inspections  a  careful 
record  will  be  made  of  all  cases  of  venereal  disease  discovered, 
and  a  report  of  the  same  be  furnished  to  the  man's  immediate 
commanding  ofhcer. 

15.  Venereal  Prophylaxis. — Each  organization  will  provide 
a  tent  or  other  place  in  which  the  venereal  prophylaxis  may 
be  administered,  and  will  keep  a  record  of  the  men  to  whom 
it  is  administered,  with  the  time  of  application  and  such  other 
information  as  may  be  necessary.  AH  men  are  directed  to 
apply  for  this  treatment  at  the  earliest  possible  time  after 
exposure,  should  such  exposure  unfortunately  occur.  All  men 
are  hereby  cautioned  against  exposing  themselves. 
By  Command  of  Major-General  Jones, 

John  Smith, 

Adjutant -General  and  Chief  of  Staff. 

Sanitary  Inspection  Form. — A  form  similar  to  this  may 
be  used  as  a  report.  When  so  used,  should  any  defect  be  found 
it  is  sent  at  once  to  the  regimental  adjutant  who  later  sends  it 
by  orderly  to  each  organization  commander  concerned.  These 
may  initial  in  the  proper  space  to  show  that  they  have  seen 
it  ard  will  correct  defects.  The  adjutant  then  sends  form  to 
the  chief  surgeon.  This  particular  form  is  purely  optional. 
Experience  has  shown  that  unless  some  such  form  be  followed 
in  making  inspections,  even  experienced  officers  will  overlook 
important  matters  that  require  attention.  There  are  so  many 
things  to  invite  attention  in  inspecting  an  organization,  that 
some  such  form  is  a  great  assistance.  Many  of  the  questions 
in  the  following  are  general,  and  suggest  a  whole  set  of  further 
questions.  It  is  suggested  that  each  medical  officer  w^ho  makes 
sanitary  inspections  should  prepare  a  Special  Sanitary  Report 
based  on  the  following  model,  but  which  will  embody  those 
questions  that  are  particularly  pertinent  to  the  camp  in 
question. 


30  SANITATION  FOR  MEDICAL  OFFICERS 

Special  Sanitary  Report. 

Date 


Camp  of     (fill  in  oiganization) 

Hour  when  inspected 

Accompanied  by  regimental  or  battalion  medical  officers? 

Are  these  officers  well  informed  as  to  local  conditions? 

Have  previous  recommendations  been  carried  out? 

Are  the  sanitary  squads  efficient? 

Is  the  general  police  of  the  camp  excellent? 

Are  sanitary  inspections  frequently  made  by  regimental  medical  officers? 

Is  the  camp  dusty  or  muddy  and  can  this  be  remedied? 

Are  the  tent  walls  raised  daily,  and  for  how  long? 

Are  the  tent  interiors  orderly  and  clean? 

Is  bedding  and  clothing  sunned  daily? 

Recommendations  as  to  clothing  and  equipment? 

Are  the  kitchens  and  cooks  clean? 

Is  food  screened  from  ffies? 

Is  it  protected  from  dust? 

Is  the  ice-box  clean  and  sweet? 

Are  flies  numerous  about  the  kitchen?    Are  fly  traps  used  efficiently? .... 
Is  the  garbage  promptly  burned?     Does  the  incinerator  function  well? .  . 

Is  the  ground  soiled  by  cooking  or  wash  water? 

Are  the  men  required  to  wash  the  hands  before  eating? 

Is  food  ample,  of  good  quality  and  well  prepared? 

Are  the  water  cans  kept  freshly  filled  and  covered? 

Is  the  ground  near  the  water  taps  kept  dry? 

Is  there  any  reason  to  suspect  water  contamination? 

Are  flies  numerous  about  the  latrines? 

Are  they  fly-tight? Properly  burned  out  daily? 

Is  toilet  paper  provided? Are  latrines  lighted  at  ni^t? 

Are  any  other  errors  noted  about  the  latrines? 

Where  may  the  men  wash  after  leaving  the  latrine? 

Are  urine  cans  used  nightly  and  properly  cleansed? 

Is  there  an  organization  lavatory? Is  it  properly  drained? 

Are  the  picket  lines  clean?  .  .  Is  the  manure  removed  and  burned  daily?  .  . 

Is  there  any  evidence  of  fly  breeding  about  picket  lines  or  kitchen? 

Is  there  any  evidence  that  the  ground  is  polluted  by  excreta? 

Are  there  any  hucksters  in  camp,  or  stands  where  food  or  drink  is  sold? .  .  . 

Is  the  milk  supply  healthful  and  satisfactory? 

Are  venereal  inspections  made? How  often? 

Is  the  venereal  prophylaxis  properly  administered?     To  how  many  men? 

Is  the  venereal  rate  of  the  organization  excessively  high? 

Is  the  general  sick-rate  unduly  high? 

Is  it  due  to  an  excess  of  admissions  for  any  one  cause? 

Is  there  any  evidence  of  vermin? Bed-bugs? Lice? 

If  mosquitoes  are  present,  are  mosquito  bars  properly  used? 

Are  there  any  other  defects  or  suggestions? 

Signature. 


THE  'CAMP  31 


« 


DIET. 


No  elaborate  discussion  of  dietary  principles  is  desirable 
in  a  hand-book  of  this  character,  but  as  a  sanitary  officer 
may  be  called  upon  at  any  time  to  express  an  opinion  as  to 
whether  a  certain  diet  is  sufficient,  he  should  have  at  hand 
the  necessary  data  upon  which  to  base  this  opinion. 

Basal  Requirements. — The  large  calorie  is  the  amount  of 
heat  necessary  to  raise  one  kilo  of  water  at  20°  C.  through 
1°  C.  It  is  obvious  that  the  energy  expended  by  a  man  in 
maintaining  the  bodily  temperature  or  in  work  must  be 
supplied  in  his  food.  The  amount  of  heat  dissipated  by  a 
man  at  absolute  rest  has  been  determined  very  accurately 
by  observ^ations  in  calorimeters.  In  accordance  wdth  such 
observations  the  minimum  basal  requirements  of  a  156-pound 
man  may  be  stated  to  be  about  as  follows,  for  a  period  of 
twenty-four  hours: 

Absolute  rest  in  bed  without  food      ....      1680  calories. 
Absolute  rest  in  bed  with  food 1840 

After  supplying  this  minimum  requirement  of  metabohsm, 
an  additional  supply  of  energy  must  be  furnished  dependent 
upon  the  amount  of  work  performed.    This  may  be  estimated 

as  follows:  Calories. 

Rest  in  bed  8  hours,  sitting  in  chair  16  hours        .       .       .      2168 
Rest  in  bed  8  hours,  sitting  in  chair  14  hours,  walking  2 

hours  (professional  men,  clerks,  etc.) 2488 

Rest  in  bed  8  hours,  sitting  in  chair  14  hours,  vigorous 

exercise  2  hours 2982 

Estimated  expenditure  of  soldier  in  barracks         .      .       .      3000 
Constant  muscular  work,  painters,  carpenters,  etc.    .       .      3300 

Farmers 3500 

Stone  masons 4500 

Lumbermen 5000 

Soldiers  marching  and  on  active  service     .       .      .   4500  to  5000 

The  energy  yield  of  the  food  constituents. 

Rubner.  Atwater. 

I  gram  protein  yields       .       .       .      4.1  calories.  4.4  calories. 

I  gram  carbohydrate  yields        .4.1        "  4  — 

I  gram  fat  yields        ....     9-3        "  9-4 


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40  SANITATION  FOR  MEDICAL  OFFICERS      > 

Amount  of  Proteid  Required. — Fat  and  carbohydrates 
furnish  energy  and  are  not  concerned  in  tissue  building. 
Proteid  forms  tissue  and  in  addition  furnishes  energy.  How- 
ever, proteid  is  an  inefficient  fuel,  so  that  so  far  as  possible 
only  sufficient  proteid  should  be  furnished  to  replace  daily 
wear  and  tear,  leaving  the  energy  to  be  supplied  by  fats  and 
carbohydrates.  Chittenden  beHeved  that  health  and  strength 
may  be  maintained  on  0.94  gram  of  protein  per  kilo  of  body 
weight  (156  pounds  =  70  kilos).  If  labor  is  not  very  severe 
this  may  be  sufficient.  The  protein  requirement  is  given  up 
to  2  grams  per  kilo  by  various  authors.  It  must  be  remem- 
bered that  the  body  requirement  of  protein  does  not  neces- 
sarily depend  upon  protein  per  se  but  upon  useful  protein. 
A  complete  protein  contains  about  17  amino  acids.  Most 
animal  proteins  are  complete,  while  many  vegetable  proteins 
are  not.  Therefore  if  the  protein  intake  is  from  vegetable 
sources,  it  may  be  necessary  to  consume  several  times  the 
actual  amount  of  protein  katabolized.  There  is  no  direct 
evidence  that  an  excess  of  protein  is  injurious,  while  there  is 
plenty  of  evidence  that  a  deficiency  in  protein  is  injurious. 
For  these  reasons,  especially  when  dealing  with  soldiers 
performing  hard  work,  it  is  not  believed  that  Voit's  standard 
should  be  materially  lowered.  It  is  w^ell  to  remember,  however, 
that  under  the  pinch  of  necessity  this  amount  of  protein  can 
be  reduced  to  Chittenden's  standard  or  even  lower  for  short 
periods. 

The  relative  proportion  of  the  food  constituents  in  well- 
ordered  dietaries  is  usually  set  down  as  about  one  part  pro- 
tein, half  a  part  of  fat,  and  four  parts  of  carbohydrates,  or  a 
proportion  of  nitrogen  to  carbon  of  i  to  16  or  i  to  18. 

Daily  food  requirements  for  a  man  of  i$6  pounds  (70  kilos): 

Chittenden.  Grams.  Calories. 

Protein 60  246 

Fat 60  558 

Carbohydrate 500  2050 

Total 2854 


THE  CAMP 


41 


Voit.                                       Grama.  Calories. 

Protein ii8  483 

Fat 56  538 

Carbohydrate 500  2050 

Total 3071 

Melville  (standard  for  ordinary  man).         Grams.  Calories. 

Protein 120  490 

Fat 60  558 

Carbohydrate 480  1970 

Total 3018 

Melville  (standard  for  hard  labor).            Grams.  Calories. 

Protein 170  697 

Fat 180  1674 

Carbohydrate 530  2173 

Total 4544 


The  U.  S.  Army  Ration;  Garrison  Ration. — By  selecting 
such  articles  as  bacon,  hard  bread,  cornmeal,  beans,  potatoes, 
dried  fruit,  butter  and  syrup  a  maximum  fuel  value  of  from 
5378  to  5674  calories  may  be  obtained.  By  using  such 
articles  as  dried  fish,  soft  bread,  rice,  potatoes,  onions,  canned 
tomatoes  and  dried  fruit  the  fuel  value  can  be  reduced  to 
2500  calories.  The  average  garrison  ration  of  fresh  beef, 
soft  bread,  beans,  potatoes,  onions,  dried  fruit,  butter  and 
syrup  and  sugar  weighs  65  ounces  and  has  a  fuel  value  of 
3536  calories  distributed  as  follows: 

Grams.  Calories. 

Protein .      i57  643 

Fat 99  921 

Carbohydrate 481  1972 

Total 3536 

Reserve  ration.  Grams.  Calories. 

Protein 113  463 

Fat .      .      218  2027 

Carbohydrate 489  2004 

Total 4494 


42  SANITATION   FOR  MEDICAL  OFFICERS 

The  travel  ration  gives  a  fuel  value  of  about  2735  calories. 

The  Filipino  ration  gives  a  fuel  value  of  about  3980 
calories.  • 

When  for  any  reason  the  ration  must  be  cut  dovrn,  the 
following  is  suggested: 

Ounces.  Calories. 

Cooked  beans I4f  800 

Pork 2  468 

Bread 5  36o 

Butter I  206 

Milk 10  200 

Coffee S  

Total 2034 

Sixteen  per  cent,  of  these  calories  are  in  protein,  one-sixth 
being  animal  proteins  complete  Grade  A. 

DEFICIENCY  DISEASES. 

Deficiency  diseases  have  appeared  in  some  of  the  prison 
camps  in  Europe,  and  have  been  very  common  in  jails, 
asylums,  and  similar  institutions  in  the  United  States.  The 
commonest  cause  of  these  diseases  appears  to  have  been  the 
too  exclusive  use  of  finely  milled  wheat  flour  over  long  periods 
of  time  Certain  foods  are  now  known  to  be  deficient  in 
certain  substances  that  have  been  called  vitamines,  and  the 
prolonged  deprivation  of  these  substances  results  in  such 
diseases  as  scurvy,  beriberi  and  possibly  pellagra.  When 
large  bodies  of  prisoners  must  be  fed,  an  observance  of  the 
following  rules  will  prevent  the  development  of  these 
deficiency  diseases. 

1.  When  bread  is  the  staple  article  of  diet  it  should  be 
made  from  whole  wheat. 

2.  When  rice  is  used  in  any  quantity,  undermilled  rice 
should  be  used. 

3.  Beans,  peas  or  other  legumes  should  be  used  once  a  week. 
These  are  not  to  be  canned,  but  may  be  dried. 


THE   CAMP  43 

4.  Some  fresh  vegetable  or  fruit  to  be  issued  at  least  once 
and  preferably  twice  a  week. 

5.  Barley  should  be  used  in  soups. 

6.  White  potatoes  and  fresh  meat  should  be  served  at  least 
once  a  week  and  preferably  daily. 

7.  The  too  exclusive  use  of  canned  foods  is  to  be  avoided. 

8.  If  cornmeal  is  used  it  should  be  made  from  the  whole 
grain. 

WATER. 

Minimum  Requirement  in  Camp. — Each  man  requires  daily 
at  least  i  quart  for  drinking,  and  2^  quarts  for  drinking  and 
cooking.  One  gallon  more  should  be  allowed  for  washing  his 
person  and  clothing.  In  the  tropics  and  warm  climates  this 
amount  must  be  increased  by  at  least  one-third.  In  semi- 
permanent camps  not  less  than  5  gallons  per  capita  should 
be  provided,  while  in  permanent  camps  with  bath  houses 
and  sewerage  not  less  than  30  gallons  must  be  provided.  In 
estimating  for  cavalry  commands  it  may  be  considered  that 
a  horse  will  drink  about  8  gallons  a  day. 

Tests  for  Purity. — In  permanent  camps  the  water  may  be 
assumed  to  be  pure  unless  there  is  specific  information  to  the 
contrary.  It  is  hardly  to  be  supposed  that  a  permanent 
camp  site  would  be  selected  that  afforded  only  an  impure 
water.  However,  should  the  water  be  suspected,  samples 
may  be  sent  to  the  nearest  Department  Laboratory  in  accord- 
ance with  the  provisions  in  the  following  circular  from  the 
Office  of  the  Surgeon-General.  In  semipermanent  camps 
the  water  may  be  sent  in  to  be  tested  in  the  same  way,  or  if 
this  is  impracticable  it  may  be  tested  by  a  field  laboratory. 
In  the  absence  of  tests  estabUshing  the  purity  of  the  water 
supply  all  drinking  water  should  be  purified.  See  note  on 
Purification  of  Water. 

W.  D.,  Office  of  the  Surgeon-General,  Washington,  August 
18,   19 10.     The  following  directions  for  the  collection  of 


44  SANITATION   FOR   MEDICAL   OFFICERS 

samples  of  water  for  bacteriological  examination  are  published 
for  the  information  and  guidance  of  all  whom  it  may  concern : 

All  samples  of  water  intended  for  bacteriological  examina- 
tion should  be  collected  by  a  medical  officer  in  the  sterilized 
bottles  furnished  with  mailing  cases,  upon  request  to  this 
office,  for  the  purpose.  These  bottles  are  prexdously  sterilized 
and  are  protected  by  a  piece  of  heavy  sterilized  muslin  secured 
by  a  copper  wire  which  is  also  intended  to  keep  the  stopper 
securely  in  place  during  transportation. 

To  collect  the  sample,  first  untwist  the  projecting  ends  of 
the  copper  wire  to  release  the  stopper ;  the  stopper  may  then 
be  loosened,  but  it  must  not  be  removed.  If  the  specimen  is 
to  be  taken  from  a  faucet  or  pump,  the  water  should  be  per- 
mitted to  run  for  fifteen  to  twenty  minutes,  then  allowing  a 
small,  gentle  stream  to  flow,  grasp  the  bottle  near  the  bottom 
and  removing  the  stopper,  permit  the  stream  to  flow  into  the 
bottle,  held  in  the  upright  position,  until  it  is  filled  to  the 
shoulder.  Then  replace  the  stopper,  screwing  it  in  tightly, 
and  secure  both  stopper  and  cloth  by  carrying  the  wire  several 
times  around  the  neck  of  the  bottle  and  twisting  the  ends 
securely.  The  stopper  must  be  handled  only  by  the  square 
cloth-covered  top  and  the  lip  of  the  bottle  must  not  be  brought 
in  contact  with  the  faucet  or  spout,  nor  should  the  neck  of  the 
bottle  or  naked  part  of  the  stopper  be  permitted  to  come  in 
contact  with  any  object  during  the  manipulation.  The 
projecting  flange  is  designed  to  protect  the  plug  of  the  stopper, 
which  it  will  do  if  the  stopper,  after  withdrawal,  is  held  by  the 
top  in  a  vertical  position.  The  stopper  should  not  be  laid 
down  and  the  cloth  should  not  be  handled  by  the  fingers 
except  in  the  act  of  securing  the  wire  about  it.  When  well 
water  is  to  be  examined  the  bottle  should  be  filled  directly 
from  the  bucket  constantly  in  use  for  drawing  the  water  and 
from  no  other  vessel.  The  label  should  be  plainly  marked 
to  show  the  source  from  which  the  sample  is  taken  and  the 
date  of  collection.    A  little  cotton  should  be  placed  in  the 


THE  CAMP  45 

bottom  of  the  mailing  case  to  insure  that  the  bottle  will  be 
held  firmly  in  position.  The  sample  should  be  plainly  marked 
"Water  for  bacteriological  examination"  and  forwarded  at 
the  earliest  moment,  by  mail  to  the  nearest  Department 
Laboratory.  On  account  of  the  labor  involved  and  the 
possibihty  of  error,  bacteriological  examinations  of  water 
collected  in  any  other  than  the  prescribed  receptacles  will  not 
be  made. 

Geo.  H.  Torney, 

Surgeon-General,  U.  S.  Army. 

MILK,  SANITARY  SUPERVISION. 

The  objects  to  be  attained  by  sanitary  control  of  milk 
suppUes  are: 

1.  Competent  veterinary  examination  of  dairy  cattle  and 
eHmination  of  those  found  diseased.  Tuberculosis  especially 
is  excluded  by  the  tuberculin  test,  and  cows  having  mas- 
titis or  inflammation  of  the  udder  should  be  excluded.  The 
streptococcus  from  this  condition  is  very  possibly  the  cause 
of  '^  septic  sore  throat." 

2.  CleanUness  of  stables,  animals,  utensils,  and  especially 
of  the  methods  of  production  and  handling  of  milk  from  the 
cow  to  the  consumer. 

3.  Maintenance  of  the  milk  continuously  at  a  sufficiently 
low  temperature  (at  least  50°  F.).  Prohibition  of  sale  of 
milk  that  is  stale  or  shows  an  excessive  bacterial  count. 

4.  Sufficient  food  values  and  freedom  from  adulteration, 
sophistication,  or  the  use  of  preservatives. 

5.  Prevention  of  infection,  human  or  animal  in  source, 
through  requirements  as  to  health  of  employees,  reporting 
of  communicable  diseases  in  the  families  of  any  persons  con- 
cerned in  the  handling  of  milk,  regulations  as  to  the  delivery 
of  milk  to  infected  families  (only  in  bottles,  never  in  bulk), 
purity  of  dairy  water  supplies,  proper  sterilization  of  milk 


46  SANITATION  FOR   MEDICAL   OFFICERS 

bottles  and  apparatus,  and  pasteurization  of  all  milk  except 
that  of  the  very  highest  grade. 
This  control  is  exercised  by: 

1.  Inspection  at  dairy  farm,  bottling  establishments,  dur- 
ing transportation  and  while  on  sale.  A  score-card  system 
is  used  in  many  cities  to  indicate  relative  purity  of  various 
dairies,  and  this  is  published.  The  pubUc  will  not  care  to 
buy  poor  milk.  In  the  military  service,  milk  from  insanitarv 
dairies  should  not  be  permitted  to  be  sold  on  military 
reservations. 

2.  Laboratory  control,  including  collection  of  samples, 
bacterial  counts,  chemical  tests,  tests  for  visible  dirt,  and 
tests  for  adulterations  and  preservatives.  Samples  of  milk, 
as  far  as  possible  in  original  containers,  may  be  sent  packed 
in  ice  to  the  nearest  Department  Laboratory  for  a  bacterial 
count,  providing  not  more  than  twenty-four  hours  are 
required  in  transit,  as  the  bacterial  count  is  worthless  in 
old  milk.  When  this  cannot  be  done,  the  milk  may  be 
examined  on  the  ground  by  a  medical  officer,  as  the  technic  is 
very  simple.    The  following  standard  method  should  be  used. 

Method. — Clean  cap  and  shake  bottle  vigorously  before 
opening.  Shaking  is  important,  since  the  majority  of  bac- 
teria rise  with  the  cream.  For  samples  of  unknown  charac- 
ter make  dilutions  of  i  to  loo,  i  to  looo,  and  i  to  10,000, 
using  sterile  water  and  pipettes.  These  dilutions  may  be 
made  by  setting  up  four  test-tubes  containing  9  c.c.  of 
sterile  water.  In  the  first  tube  place  i  c.c.  of  the  milk  to  be 
tested,  making  a  dilution  of  i  to  10.  Mix  well  and  carry 
I  c.c.  to  the  second  tube,  making  a  dilution  of  i  to  100.  By 
the  same  process  tube  3  makes  a  dilution  of  i  to  1000  and  tube 
4  a  dilution  of  i  to  10,000.  One  c.c.  of  the  last  three  dilu- 
tions are  plated.  Place  the  milk  in  a  sterile  Petri  dish  and 
pour  in  a  tube  of  melted  agar  that  has  been  cooled  to  50°  C. 
Invert  the  plates  after  they  have  hardened  and  incubate 


THE  CAMP  47 

for  forty-eight  hours,  after  which  the  colonies  are  counted, 
using  a  small  hand  lens  if  possible. 

Grading  Milk. — Some  standard  is  necessary.  The  following, 
used  by  the  New  York  Board  of  Health,  is  excellent. 

Grade  A. — Milk  for  infants  to  drink:  If  used  raw  must 
not  contain  more  than  60,000  bacteria  per  cubic  centimeter. 
If  pasteurized  must  not  contain  more  than  200,000  before 
pasteurization  and  not  more  than  30,000  after  pasteurization. 

Grade  B. — Milk  for  adults  to  drink:  Is  all  pasteurized  and 
should  not  contain  more  than  1,500,000  bacteria  per  cubic 
centimeter  before  pasteurization  and  not  more  than  100,000 
after  pasteurization. 

Grade  C. — Milk  for  cooking  only:  All  pasteurized,  and 
must  not  contain  more  than  300,000  bacteria  per  cubic 
centimeter  after  pasteurization. 

Milk  used  by  soldiers  should  all  be  pasteurized.  Efficient 
pasteurization  destroys  practically  all  disease  organisms, 
including  those  of  t}^hoid,  foot-and-mouth  disease,  septic 
sore  throat,  and  other  diseases  that  may  be  milk-borne.  If 
camps  are  located  where  a  pasteurized  supply  cannot  be 
obtained  it  would  be  wise  to  use  only  canned  milk  or  to  have 
all  milk  pasteurized  at  the  hospital  under  the  supervision  of 
the  surgeon. 

Pasteurization. — Several  firms  make  pasteurizers  capable 
of  handUng  20  gallons  and  up.  Most  of  these  depend  upon 
the  use  of  electric  or  other  power  for  stirring  the  milk.  The 
American  Pasteurizer  Company,  of  Washington,  D.  C,  has 
under  construction  a  small  apparatus  that  can  be  used  at 
hospitals.  This  apparatus  will  pasteurize  milk  in  bottles, 
will  be  heated  by  an  oil  stove,  and  the  entire  apparatus 
packs  into  the  pasteurizer  tank,  which  is  4  feet  long,  2  feet 
high,  and  15  inches  wide.  The  entire  apparatus,  including 
oil  stove,  will  cost  in  the  neighborhood  of  $100. 

A  pasteurizer  can  be  improvised  from  a  wash  boiler  or 
similar  water  container.    The  milk  bottles  or  cans  are  stood 


48  SANITATION  FOR  MEDICAL  OFFICERS 

on  bricks  in  the  container,  water  is  poured  into  the  container 
up  to  the  neck  of  the  cans  or  to  the  lip  of  the  bottles.  The 
water  is  heated  while  the  milk  is  stirred  until  the  temperature 
of  the  milk  is  145°  F.  This  temperature  is  maintained  for 
half  an  hour,  after  which  the  hot  water  is  drawn  off  and  the 
milk  is  rapidly  cooled  to  45°  F.  or  less  by  pouring  cold 
water  into  the  container.  The  milk  is  then  placed  in  the 
ice-box. 

The  Investigation  of  Supposed  Milk-borne  Epidemics. — 
Cover  the  following  points : 

1.  The  number  of  cases  of  the  disease  existing  in  the  terri- 
tory involved  during  the  time  covered  by  the  epidemic. 

2.  The  number  and  location  of  houses  invaded  by  the 
disease. 

3.  The  number  of  invaded  houses  supplied  in  whole  or  in 
part,  directly  or  indirectly  with  the  suspected  milk. 

4.  The  number  of  cases  occurring  in  the  invaded  houses  so 
suppUed. 

5.  The  total  number  of  houses  supplied  with  the  suspected 
milk. 

6.  The  relative  proportion  of  houses  so  supplied  to  those 
supplied  by  other  dairies. 

7.  The  time  covered  by  the  epidemic. 

8.  The  location  of  the  case  or  cases  from  which  the  milk 
became  infected,  and  the  relation  of  this  case  to  the  milk. 

9.  The  time  relation  of  the  original  case  to  the  epidemic. 

10.  The  special  incidence  of  the  disease  among  milk 
drinkers,  and  among  those  using  the  particular  milk  supply 
investigated. 

11.  The  elimination  by  a  process  of  exclusion  of  other 
common  means  of  transmission  of  the  disease  in  question. 

12.  The  effect  upon  the  epidemic  of  closing  the  dairy,  or  of 
taking  such  measures  as  would  prevent  future  contamina- 
tion from  the  suspected  source. 

13.  The  finding  of  the  specific  organism  in  the  milk. 


THE  CAMP 
DISPOSAL  OF  WASTES. 


49 


regi- 


RocK-PiLE  Crematory. — For  the  general  use  of  a  _ 
mental  or  brigade  camp  where  fuel  and  stones  are  plentiful, 
and  in  the  absence  of  special  appHances,  there  is  nothing 
better  than  this  type  of  crematory  for  the  incineration  of 
garbage  and  refuse,  soUd  and  liquid.  It  is  thus  described  in 
specifications  from  the  office  of  the  Chief  of  the  Quarter- 
master Corps,  January,  1908. 

At  some  convenient  location  a  circular  pit  is  dug,  3  feet 
in  depth  and  15  feet  in  diameter.  The  bottom  to  be  covered 
with  loose  stones  to  the  depth  of  14  to  16  inches.  On  this  is 
built  a  circular  wall  to  the  height  of  i  foot  above  the  original 


.-*.-*.-..— .j5"0'Di  AM  E.TEJ5 — — ...  — 


Fig.  I. — Rock-pile  crematory. 

ground  line,  and  the  excavated  earth  is  packed  against  it 
clear  to  the  top  so  as  to  provide  a  sloping  approach  and 
thereby  prevent  surface  water  gaining  access  to  the  pit. 
A  pyramid  of  large  stones,  4  or  5  feet  high,  occupies  the  cen- 
ter. This  feature  is  essential  to  provide  central  draft  and 
steady  fire. 

The  bottom  stones  receive  the  Uquid  portions  of  the  g.ar- 
bage  without  affecting  the  fire,  and  soon  evaporate  and  dis- 
sipate them.  The  soHd  portions  are  soon  desiccated  and 
become  fuel.  Care  should  be  exercised  to  empty  the  gar- 
bage into  and  not  around  the  crematory.  It  is  desirable  to 
4 


60  SANITATION  FOR  MEDICAL  OFFICERS 

place  a  few  heavy  stones  along  the  edge  of  the  pit  to  serve 
as  bumpers  or  guard  to  the  rear  wheels  of  carts. 

This  crematory  has  been  repeatedly  used  and  has  given 
general  satisfaction.  Only  one  man  is  required  for  its  ser- 
vice. One  cord  of  wood  will  consume  approximately  4500 
pounds  of  refuse  and  garbage,  including  kitchen  wastes  and 
slops.  It  will  likewise  incinerate  manure  and  dead  animals. 
(From  Havard,  Military  Hygiene.) 

The  Company  Incinerator. — The  following  was  designed 
by  Major  Straub,  M.C.  It  consists  of  a  bed  of  rocks  level 
with  the  ground,  i  foot  deep,  3  feet  wide,  and  4 J  feet  long, 
surrounded  with  a  sloping  stone  wall  18  inches  high  except 
at  one  end,  which  is  left  open  for  draught,  fuel,  and  access 
to  the  fire.  The  stone  wall  absorbs  much  of  the  heat  that 
would  otherwise  be  dissipated  and  increases  the  evaporating 
capacity  of  the  crematory.  With  ordinary  care  and  atten- 
tion about  J  cord  of  wood  per  day  is  sufficient  for  the  destruc- 
tion of  all  slops  and  garbage,  i.  e.,  will  destroy  100  gallons  of 
Uquids  and  23  cubic  feet  of  soHd  garbage  in  about  twelve 
hours.  The  liquid  slops  are  evaporated  by  being  poured 
slowly  along  the  sloping  walls  frequently,  but  only  a  few 
dipperfuls  at  a  time,  while  the  solid  garbage  is  placed  over 
the  fire-bed  on  top  of  the  fuel.  When  liquids  are  excessive 
they  may  be  partly  evaporated  in  a  tin  boiler  placed  on  the 
fire. 

Caldwell  Crematory. — Intersecting  trenches  10  feet 
long,  I  foot  wide,  and  15  inches  deep  at  middle  and  gradually 
becoming  shallower  at  each  end  to  the  surface  level.  On  the 
intersection  a  grate  is  made  and  a  barrel  is  placed  over  the 
grate.  The  barrel  is  lined  with  clay  and  burned  out  so  that 
a  chimney  is  constructed.  In  place  of  the  barrel,  a  sheet- 
iron  cyhnder  may  be  used  when  obtainable.  Of  the  various 
openings,  the  ones  to  leeward  are  closed,  and  the  fire  started, 
after  which  garbage  and  waste  may  be  dropped  down  the 
chimney.     This  crematory  which  can  be  improvised  any- 


THE   CAMP 


51 


where  will  burn  the  garbage  and  refuse  of  a  battalion.  If 
the  gratmg  is  unobtainable  the  iron  cylinder  may  be  used 
alone  by  having  apertures  cut  in  the  base  to  furnish  draught. 
Another  type  of  incinerator  may  be  made  of  a  grating  of 
railroad  iron  supported  by  bricks  or  stones  or  a  mud  wall  on 
three  sides. 


cafs    Jccr/ov ^e 


Fig.  2. — The  Straub  garbage  crematory.     (From  Havard,  Military- 
Hygiene.) 


The  only  absolute  bar  to  the  use  of  an  incinerator  is  lack 
of  fuel  in  a  wet  cHmate.  Under  these  conditions  some  wastes 
will  have  to  be  carried  away  and  buried  in  deep  pits.    Such 


52  SANITATION  FOR  MEDICAL  OFFICERS 

conditions  are  very  rare,  as  crude  oil  can  be  obtained  almost 
anywhere.  A  barrel  of  this  oil  costs  less  than  the  services  of 
one  man  per  day,  so  it  should  be  used  extensively  as  a  matter 
of  economy. 

To  each  infantry  regiment  the  Quartermaster  should 
assign  one  wagon  daily  and  three  to  each  cavalry  regiment 
to  haul  refuse  and  manure  from  the  kitchens  and  picket 
lines  to  the  incinerators.  The  same  wagons  may  be  able  to 
serve  several  organizations  during  the  day. 

The  Guthrie  incinerator  may  also  be  used.  A  detailed  drawl- 
ing for  the  construction  of  this  incinerator  may  be  found  in 
the  Manual  for  the  Quartermaster  Corps. 

A  multiple  shelf  incinerator  has  been  devised  recently  by 
Major  Charles  Williamson.  This  incinerator  consists  of  a 
rectangular  brick  chimney,  4 J  by  6  feet  inside  diameter, 
w^ith  a  grate,  and  above  the  grate  a  series  of  six  drying  shelves, 
w^hich  overlap  so  as  to  cause  the  heat  to  be  deflected  from 
front  to  rear  of  each  shelf.  The  garbage  is  thrown  in  at  the 
top  of  the  stack,  which  is  12  feet  high,  and  is  then  pushed 
from  one  shelf  to  the  next  lower  one  by  a  long-handled  hoe. 
The  garbage  is  thus  gradually  dried,  and  when  it  reaches  the 
bottom  shelf  it  soon  begins  to  take  fire  and  is  then  pushed 
off  the  lowest  shelf  to  the  fire  gra.te.  From  this  point  on  no 
further  wood  is  used,  and  the  garbage  furnishes  more  than 
sufficient  heat  to  incinerate  itself.  The  incinerator  is  started 
by  loading  all  the  shelves  with  a  thin  layer  of  garbage  and 
building  a  fire  until  the  garbage  on  the  lowest  shelf  catches 
fire,  when  fuel  consumption  is  at  an  end.  Two  hundred 
pounds  of  w^ood  starts  the  furnace,  after  which  the  incinerator 
may  be  operated  continuously  without  further  fuel.  The 
normal  capacity  of  this  incinerator  is  10  to  15  tons  of  garbage 
in  twenty-four  hours.  It  will  also  dispose  of  feces  and 
manure.  It  is  suitable  for  permanent  camps,  cantonments, 
hospitals  and  organizations  having  considerable  waste  for 
incineration.    One  can  probably  take  care  of  the  waste  from 


THE  CAMP  53 

a  division  if  operated  continuously.  For  details  of  construc- 
tion see  article  by  Major  Williamson  in  the  Military  Surgeon, 
1918,  xliii,  no. 

In  temporary  camps  garbage  cans  are  objectionable,  and 
when  company  incinerators  are  used  are  generally  forbidden 
by  camp  orders.  But  in  permanent  camps  where  incinerators 
are  not  used  there  is  no  objection  to  an  arrangement  with 
responsible  civilians  to  remove  garbage  from  camps  and 
cantonments  provided  such  removal  is  prompt  and  carried 
out  under  regulations  which  will  ensure  that  no  insanitary 
conditions  result.  Garbage  to  be  removed  in  the  can.  No 
dumping  into  wagons  permitted.  Returned  can  to  be 
thoroughly  cleansed ;  sterilization  by  steam  is  desirable. 

When  cans  are  used  they  should  be  kept  tightly  covered, 
upon  a  raised  platform,  so  that  nothing  can  accumulate  under 
and  between  the  cans,  and  the  greatest  care  must  be  used  to 
avoid  soiling  of  the  ground  around  the  cans,  as  this  is  certain 
to  attract  flies  in  large  numbers.  The  ground  may  be  oiled. 
Cans  washed  in  lye  often  bring  flies  back  to  camp.  Washing 
them  with  a  creosote  compound  prevents  this.  When  gar- 
bage is  fed  to  pigs  on  nearby  farms  a  fly  pest  may  be  created 
if  farmers  take  more  garbage  than  the  pigs  can  consume  in  a 
day.  The  feeding  pens  should  be  cleaned  daily  and  the 
remains  of  the  day's  feeding  should  be  burned. 

Disposal  of  Manure  and  Care  of  Picket  Lines.— 
Flies  breed  preferably  in  manure,  so  that  particular  attention 
must  be  given  to  the  manure  and  refuse  from  the  picket 
lines  and  stables.  AH  manure  and  straw  should  be  hauled 
awav  daily  and  burned  or  otherwise  disposed  of  as  directed 
by  the  sanitary-inspector.    Picket  lines  will  be  kept  broom- 

t  swept  and  all  manure  and  straw  hauled  off  daily.  A  weekly 
incineration  of  the  picket  lines  will  be  accomplished  with 
I  crude  oil  at  the  rate  of  ten  gallons  to  each  line.  Crude  oil 
may  be  obtained  from  the  Quartermaster  Corps  on  usual 
requisition. 


54 


SANITATION  FOR  MEDICAL  OFFICERS 


Manure  may  be  burned  in  windrows.  The  space  between 
the  windrows  should  be  cleaned  to  the  surface  of  the  ground 
and  the  interval  between  the  windrows  should  be  sufficient 
to  permit  driving  between  them  while  one  is  burning. 


Fk;.  3. — Railroad-iron  incinerator.  This  incinerator  was  partly- 
burned  out  when  the  photograph  was  taken.  Ordinarily  the  manure 
is  piled  higher  than  here  indicated.  Lewis  and  Miller,  the  Military- 
Surgeon,    May,   191 7. 


In  a  dry  climate  a  railroad  iron  incinerator  will  dispose 
of  ijom  25  to  50  loads  of  manure  daily.  The  rails  forming 
the  floor  should  be  laid  at  right  angles  to  the  long  axis  of  the 
incinerator  and  parallel  to  the  direction  of  the  prevailing 
wind.    This  destroys  manure  promptly  before  fly  larvae  can 


THE  CAMP  55 

escape  into  the  soil.  No  oil  or  purchased  fuel  is  necessary 
except  during  wet  weather,  but  waste  lumber,  boxes  and 
other  rubbish  may  be  used  as  fuel.     (See  Fig.  3.) 

These  precautions  will  minimize  fly  breeding  about  picket 
lines,  but  they  will  not  obviate  it  for  the  following  reasons: 
Even  though  the  manure  be  completely  removed,  many  flies 
will  lay  their  eggs  upon  the  ground,  soiled  with  manure 
and  urine  from  the  horses,  and  the  larvae  will  burrow  into 
the  ground  within  twenty-four  to  forty-eight  hours.  Subse- 
quent burning  of  the  ground  wih  not  kill  them,  for  the  heat 
only  penetrates  the  ground  a  short  distance.  To  prevent 
this  the  soil  about  the  picket  line  should  be  dug  up  and 
saturated  w^ith  oil  and  then  tamped  hard. 

Care  of  Manure  in  Temporary  Camps. — Under  cir- 
cumiStances  when  manure  cannot  be  burned,  borax  or  helle- 
bore may  be  used.  Two-thirds  of  a  pound  of  borax  should 
be  used  to  each  10  gallons  of  w^ater  or  one-half  pound  of 
powdered  hellebore  per  10  gallons.  Ten  gallons  of  borax 
solution  sprinkled  over  8  bushels  of  manure  is  the  most 
effective  and  least  expensive  larvacide.  If  manure  is  treated 
in  this  manner  as  soon  as  it  accumulates,  fly  breeding  in  it 
will  be  prevented.  The  method  is  only  recommended  in 
case  incineration  is  impossible. 

Should  both  of  these  methods  be  impracticable  the  fol- 
lowing method  may  be  used.  When  manure  accumulates  in 
a  heap,  fermentation  causes  the  temperature  to  rise  in  the 
center  of  the  mass,  and  after  forty-eight  hours  a  tempera- 
ture of  70°  to  90°  C.  may  be  found  in  the  center.  Turn  the 
heap  over  so  as  to  bring  the  surface  where  the  larvae  are  to 
the  interior  of  the  heap,  and  the  larvae  will  be  killed  at  once 
w^hen  they  come  in  contact  with  the  hot  parts  in  the  interior. 
When  adding  fresh  manure,  do  not  add  on  top  of  the  heap 
but  bury  in  the  hot  parts. 

Manure  may  also  be  piled  on  a  platform  under  which  is  a 
tray  of  water.    As  the  larvae  work  out  at  the  bottom  of  the 


56  SANITATION  FOR  MEDICAL  OFFICERS  i 

pile  in  order  to  burrow  into  the  ground  to  pupate,  they  fall 
into  the  water  and  are  killed. 

Latrines. — The  type  of  latrine  used  must  necessarily 
differ  in  accordance  with  the  location  and  the  character  of 
the  service.  In  permanent  camps  a  water-carriage  system 
or  incinerators  may  be  used.  Incinerators  are  not  mobile, 
and  this  fact  together  with  the  cost  of  installation  precludes 
their  use  except  in  permanent  camps. 

In  Semipermanent  Camps. — Deep  trenches  or  pits  with 
some  form  of  latrine  box  are  generally  used.  Such  trenches 
should  be  7  or  8  feet  deep,  2  feet  wide  at  the  mouth  and  as 
wide  at  the  bottom  as  the  ground  will  permit  without  caving 
in.  A  trench  20  feet  long  will  seat  10  men  or  about  8  per 
cent,  of  a  company  at  war  strength.  The  size  of  the  trench 
must  depend  upon  the  type  of  latrine  box  to  be  used,  for  the 
box  must  fit  well  over  the  pit  in  order  to  be  fly-tight.  A 
shelter  must  be  built  to  ensure  privacy  and  to  protect  the 
men  from  rain.  Latrines  are  located  about  50  yards  to  the 
rear  of  the  company  street. 

Latrine  Boxes. — Should  be  made  of  well-seasoned,  tongued 
and  grooved  boards  of  a  uniform  width  and  free  from  knot 
holes.  The  holes  should  be  ovoid  and  have  self-closing  lids. 
The  box  should  have  handles  so  that  it  can  be  easily  carried, 
and  should  rest  upon  a  frame  so  as  to  make  contact  with  the 
ground  closer  and  to  protect  the  edges  of  the  pit  from  wear. 
A  tin  strip  may  be  placed  to  deflect  urine  away  from  the  box. 
The  latrine  box  designed  by  Major  Straub  and  variously 
modified  by  Majors  Lyster  and  Miller  has  been  very  gener- 
ally used  with  satisfactory  results. 

Major  Hopwood  has  designed  another  type  of  box  which 
affords  equal  accommodation  with  the  use  of  less  material. 
A  urinal  trough  is  not  used  with  this  box.  These  are  often 
difficult  to  improvise  and  the  connection  between  the  latrine 
box  and  the  urinal  is  seldom  made  in  a  satisfactory  manner. 
A  can  is  therefore  used  instead.    This  is  a  stock  article  and 


THE  CAMP 


67 


answers  every  requirement.  Latrine  boxes  are  made  by  the 
Quartermaster  Corps.  They  should  be  inspected  on  deliv- 
ery to  be  sure  that  they  are  fly-tight  and  of  proper  construc- 
tion.   When  made  of  green  lumber  they  are  most  unsatis- 


-BACK  SAME  KETG'Hr 
AS  LIDS'' 


HANDLE  BLOCKS 
.     2"x  4" 

2"x  4"aCTING  as 
LEGS  WHEN   BOX   IS 
TURNED  OVER 


LEATHER 
STRAP  HINGES 


BBAC 
INSIDE  BOX 


1   X  4  StRIP  INSlOE 
ON  WHICH  BOX   SETS 
MAKING  IT  FLY  PROOF 

COLLAR   l"x  s" 


Fig.  4. — Latrine  box  used  in  the  camps  at  Columbus.     (Lewis  and 

Miller.) 


12' 

GROUND  AVAILABLE  FOR  TURNING 
BOX  BACKWARD  IN  BURNING  PIT 


za. 


LATRINE  BOX 


SCREEN 


o 

URINAL 


gTt 


DOOR 


—a 

^ 


_^ 


Fig.  5. — Ground  plan  of  latrine  box,  latrine,  screen  and  urinal  can  used 
at  Columbus.     (Lewis  and  Miller.) 


68  SANITATION  FOR  MEDICAL  OFFiCERS 

factory,  as  they  warp  and  the  boards  shrink  so  that  cracks 
appear  everywhere  through  which  flies  may  pass. 

Care  of  Latrines. — (a)  The  latrines  will  be  burned  out 
daily  with  crude  oil  and  hay.  (Each  burning,  i  gallon  crude 
oil  and  15  pounds  hay  or  straw.) 

{b)  The  boxes  will  at  all  times  be  kept  fly- tight;  this 
implies  closure  of  all  cracks,  care  of  the  hinges  and  back 
construction  so  that  the  lids  drop  automatically.  The  latrine 
seats  will  be  w^ashed  daily  with  soap  and  water,  and  washed 
off  twice  weekly  with  a  i  to  100  solution  of  cresol  or  other 
disinfectant. 

{c)  When  filled  to  within  2  feet  of  the  top,  latrines  will  be 
filled  with  dirt  to  within  six  inches  of  the  surface  and  covered 
with  a  layer  of  sacking  soaked  in  crude  oil  to  extend  three 
feet  beyond  the  edges  of  the  pit ;  the  latter  will  then  be  filled 
in  with  earth  and  the  location  marked,  and  new  latrines 
constructed. 

In  some  districts  the  practice  of  burning  latrine  pits  has  J 
been  discontinued  and  the  following  method  whidi  will  be  f 
recommended  in  future  orders,  is  used.  The  inside  of  the 
box  and  the  sides  of  the  pit  are  thoroughly  blackened  with 
a  mixture  of  i  pound  of  bone-black  and  3  gallons  of  crude 
oil.  For  this  purpose  a  spray  pump  (F.  E.  Myers  &  Bro., 
Ashland,  Ohio,  Cat.  No.  319,  Fig.  1410)  is  issued  to  each 
regiment.  The  application  is  repeated  every  ten  days. 
The  contents  of  the  pit  are  thoroughly  covered  each  day  with 
i\  gallons  of  the  bone-black-oil  mixture,  using  an  ordinary 
sprinkling  can  for  the  puipose.  It  is  claimed  that  flies  do 
not  enter  this  pit  if  ordinary  precautions  are  taken  and  that 
the  pit  does  not  fill  up  as  rapidly  as  when  burning  is  resorted 
to.  The  urine  cans  are  emptied  when  the  latrine  seat  is 
removed  for  oiUng  the  pit,  and  are  then  burned  out  with 
one-half  pint  of  crude  oil.  No  more  oil  should  be  used  or  the 
can  will  be  injured  by  the  heat.    After  burning  out  the  can, 


f 

THE  CAMP  59 

another  half -pint  of  oil  is  added  to  form  a  protective  film 
over  the  urine  subsequently  deposited. 

Seating  Capacity. — Seating  capacity  for  latrines  should 
never  be  less  than  3  per  cent,  of  the  command,  should  be  5 
per  cent,  for  small  commands  under  500  men,  and  should  be 
8  to  10  per  cent,  in  permanent  camps. 

Washing  Facilities. — In  every  latrine  a  water  can  with 
spigot,  and  several  basins  with  soap  should  be  provided  as 
an  essential  part  of  the  equipment.  Towels  can  usually  not 
be  provided,  and  every  man  should  carry  his  own.  Washing 
the  hands  after  leaving  the  latrine  box  should  be  compelled 
by  camp  orders  in  order  to  prevent  contact  infection.  A 
basin  of  tricresol  solution  may  be  provided- for  disinfection  of 
hands. 

Improvised  Incinerator. — A  small  barrel  may  be  used  as  a 
model  for  a  cement  jacket  which  should  be  4  inches  thick 
and  30  inches  high;  12  inches  from  the  ground  iron  bars  are 
inserted  to  form  a  grid,  and  the  cylinder  and  grid  should 
rest  upon  stones  or  brick  with  proper  opening  for  a  draught. 
MacPherson  {Jour.  R.A.M.C.,  191 5)  has  described  a  simple 
scheme  where  by  using  such  an  incinerator  each  man 
destroyed  his  own  excreta.  Empty  biscuit  tins  are  cut  in 
half  and  used  as  troughs,  one  for  urine  and  one  for  feces. 
Pieces  of  newspaper  are  placed  in  the  rear  tin.  When  the 
man  has  finished  he  empties  the  urine  into  an  absorption 
pit,  and  taking  hold  of  the  four  corners  of  the  paper,  places 
it  and  its  contents  in  the  incinerator.  One  such  incinerator 
will  destroy  the  feces  of  1000  men,  but  it  is  essential  that 
any  unit  using  this  scheme  should  be  well  disciplined  and 
determined  to  make  it  a  success.  Fuel  must  be  used  in  the 
incinerator,  preferably  coal.  If  a  hot  fire  is  maintained  the 
excreta  are  reduced  to  an  impalpable  ash.  The  incinerator 
'  and  the  urine  pit  or  can  should  be  placed  near  the  front  of 
the  latrine  enclosure,  with  a  row  of  ten  troughs  at  the  rear. 
A  sanitary  orderly  is  required.    Every  mornmg  the  tins  are 


60 


SANITATION  FOR  MEDICAL  OFFICERS 


washed  out  with  a  cresol  solution,  the  floor,  which  should 
preferably  be  of  a  hard  nature,  is  swept  and  a  fire  is  built 
in  the  incinerator.  The  orderly  should  cut  papers  of  a  proper 
size  to  fit  the  troughs  and  these  are  hung  on  a  nail  above  the 
troughs.  Toilet  paper  is  of  course  supplied.  When  consider- 
ing incineration  it  may  be  estimated  that  each  man  will 
produce  5  ounces  of  feces  daily,  together  with  about  5  ounces 


HOPPER 


Grease  Box 


Water  Level 


tat 


Boards 


Outlet 


SECTION 


I 


'.'  Grease  Box  '^ 

/.Tin  Biscuit  >  . 
.   >  ',^:  Box-  ',y'^ 


Fat  Board 


Outlet 


PLAN  • 

Fig.  6. — Grease  trap. 

of  "defecation  urine."  One  thousand  men  produce  about 
600  pounds  a  day,  and  would  require  about  330  pounds  of 
wood  fuel  for  incineration. 

Disposal  of  Waste  Water. — In  camps  that  are  to  be  of  some 
duration,  but  are  supplied  with  no  drainage  system,  waste 
water  must  be  disposed  of  in  some  manner  without  fouling 
the  surface  of  the  ground. 


THE  CAMP  61" 

Kitchen  Slops. — These  may  usually  be  disposed  of  in  soakage 
pits  providing  all  grease  is  removed  from  the  water.  ^  If 
grease  runs  in  to  such  a  pit  it  soon  forms  an  impervdous 
coating  which  prevents  further  absorption  and  becomes  very 
foul.  In  constructing  a  soakage  pit  for  small  and  temporary 
camps,  dig  a  hole,  4  feet  cube,  and  fill  to  within  six  inches  of 
the  top  with  broken  brick,  clinkers  or  stones.  Earth  is  thrown 
over  the  surface  and  pounded  down.  In  the  center  leave  a 
circular  hole  to  fit  a  funnel.  This  is  packed  with  hay  or,  better 
still,  with  sand.  The  water  is  throwTi  into  this  hopper  and 
the  grease  is  deposited  on  the  hay  or  sand  as  it  cools.  The 
!  clear  water  runs  into  the  pit  and  drains  off  into  the  ground. 
The  hay  should  be  burned  every  day  or  two  in  the  incinerator. 
In  camps  of  longer  duration  a  larger  pit  should  be  dug  and 
provided  with  a  more  suitable  grease  trap.  Fig.  6  shows 
such  a  grease  trap  that  has  given  satisfaction. 

OVERCROWDING  AND  CONTACT  INFECTION. 

It  is  a  well-recognized  fact  that  overcrowding  of  a  bar- 
rack or  camp  favors  the  transmission  of  most  diseases, 
including  the  inflammations  of  the  respiratory  passages,  and 
many  diseases  become  epidemic  from  this  cause. 

Tuberculosis. — The  extent  to  which  the  development  of 
tuberculosis  is  favored  by  overcrowding  may  be  seen  by  a 
single  instance.  In  1857  a  Royal  Commission  w^as  instructed 
to  inquire  into  the  conditions  of  barracks  and  hospitals  in  the 
United  Kingdom.  It  was  found  that  one-quarter  of  the  army 
lived  in  rooms  affording  less  than  350  cubic  feet  per  man 
and  only  about  6  per  cent,  enjeyed  a  per  capita  allowance 
of  550  cubic  feet.  The  death-rate  for  tuberculosis  was  much 
higher  among  soldiers  than  for  the  civilian  population.  The 
commission  recommended  that  600  cubic  feet  should  be 
allowed  for  each  man,  an  improvement  that  was  gradually 
carried  out,  and  the  death-rate  for  tuberculosis  fell  from  2.78 
!  per  1000  to  0.31  per  1000. 


62  SANITATION  FOR  MEDICAL  OFFICERS 

Pneumonia. — This  disease  became  epidemic  both  on  the 
Canal  Zone  and  in  the  mines  at  the  Rand.  General  Gorgas 
stated  that  he  was  satisfied  that  the  scattering  of  the  negroes 
was  the  chief  cause  of  the  sudden  and  permanent  drop  in 
pneumonia  on  the  Isthmus. 

Measles,  mumps,  cerebrospinal  meningitis,  tonsillitis, 
common  colds,  and  other  respiratory  diseases  are  all  favored 
by  overcrowding  because  direct  contact  infection  is  greatly 
facilitated.  The  same  thing  is  true  of  typhoid,  dysentery, 
and  other  intestinal  diseases  that  may  be  spread  by  contact. 
Typhus  is  also  spread  by  close  contact  which  may  permit 
tfhe  infestation  of  an  entire  company  from  a  single  lousy 
individual. 

Amount  of  Space  to  be  Allowed  Each  Man. — Sanitarians 
have  agreed  that  to  afford  a  proper  air  space  for  ventilation 
without  a  draught,  a  minimum  of  7  20  cubic  feet  per  man  must 
be  allowed,  and  that  any  permanent  barracks  must  be  con- 
structed so  as  to  allow  at  least  1000  cubic  feet  per  man. 
But  for  the  purpose  of  avoiding  contact  infection,  the  amou'nt 
of  floor  space  allowed  each  man  is  much  more  important 
than  the  number  of  cubic  feet.  The  floor  space  should  never 
be  less  than  10  by  6,  or  60  square  feet,  which  with  a  ceiling 
12  feet  high  would  afford  720  cubic  feet.  Whenever  possible 
the  floor  space  should  be  80  square  feet,  affording  960  cubic 
feet. 

Although  military  necessity  may  make  such  a  rule  imprac- 
ticable in  the  field  or  in  some  camps,  nothing  less  than  stern 
military  necessity  should  cause  any  reduction  in  this  amount 
of  floor  space,  for  the  amount  proposed  as  a  standard  is  not 
a  high  ideal  but  an  irreducible  minimum  for  the  maintenance 
of  health.  Should  an  epidemic  occur,  and  should  the  soldiers 
be  overcrowded,  it  may  be  assumed  axiomaticallv  that  the 
epidemic  cannot  be  checked  by  other  sanitary  measures 
alone,  but  that  they  must  be  combined  with  measures  to 
relieve  the  overcrowding. 


THE  CAMP  63 

I  The  Trade  in  Saliva. — Closely  connected  with  the  sub- 
"  ject  of  contact  infection  is  the  perpetual  trade  in  saliva. 

The  fingers  and  various  objects  are  brought  in  contact  with 
I  the -mouth  or  nose,  and  these  secretions,  often  containing 

some  infection,  are  transferred  to  other  people  either  directly 
1  or  by  means  of  some  intermediate  object.  To  prevent  this 
j  in  camp  and  barracks  the  following  notice  may  be  advan- 
1  tageously  posted  in  conspicuous  places. 

To  Avoid  Spreading  Disease. 
I 

Do  not  spit. 

Do  not  put  the  fingers  in  the  mouth  unnecessarily. 

Do  not  pick  the  nose  or  wipe  it  on  the  hand  or  sleeve. 
!      Do  not  put  pencils  in  the  mouth. 

,  Do  not  put  anything  in  the  mouth  without  a  good  reason, 
j  and  never  when  it  has  been  in  another's  mouth. 

Do  not  use  a  common  drinking  cup.    Use  your  own. 

Never  cough  or  sneeze  into  the  air  or  in  another  person's 
face. 

Use  a  handkerchief. 

If  the  hands  become  soiled  with  saliva  or  nasal  secretion, 
(Wash  them. 

If  you  use  another  man's  tobacco  pouch  do  not  close  it 

with  your  teeth. 

VENTILATION. 

I     General  Principles. — All  recent  work  indicates  that  the 
!  effect  produced  by  the  air  of  a  badly  ventilated  room  is  pri- 
'  marily  due  to  the  increase  in  temperature  and  humidity,  and 
ithat  these  conditions  are  largely  aggravated  by  any  want 
!of  movement  in  the  air.    Decrease  of  oxygen  or  increase  of 
carbon  dioxide  are  not  of  direct  importance.     The  propor- 
tion of  oxygen  present  in  even  the  worst  ventilated  rooms 
varies  but  slightly  in  amount  from  that  in  the  air  of  the  open 
country,  while  if  temperature  and  humidity  are  kept  at  the 

i 


64  SANITATION  FOR  MEDICAL  OFFICERS 

proper  point  it  is  possible  to  work  in  a  room  with  a  propor- 
tion of  CO2  as  high  as  60  per  10,000.  Some  of  the  conchi- 
sions  of  the  New  York  State  Commission  on  Ventilation  are 
as  follows: 

8.  These  experiments  seem  to  indicate  that  overheated 
rooms  are  not  only  uncomfortable,  but  produce  well-marked 
effects  upon  the  Reat  regulating  and  circulatory  systems  of 
the  body,  and  materially  reduce  the  incHnation  of  the  occu- 
pants to  do  physical  work.  The  most  important  effects  of 
bad  air  are  due  to  its  high  temperature,  and  the  effects  of 
even  a  sUghtly  elevated  room  temperature  such  as  75°  F. 
are  sufficiently  clear  and  importani  to  warrant  careful  pre- 
cautions against  overheating. 

9.  The  chemical  changes  in  the  breathed  air  of  occupied 
rooms  are  of  a  comparatively  minor  importance,  although 
the  substances  present  in  such  air  may  exert  a  slight  decrease 
in  the  appetite  for  food. 

But  while  the  quantities  of  CO2  in  even  the  worst  venti- 
lated room  do  not  account  for  the  effects  of  bad  ventilation, 
the  percentage  of  this  gas  is  still  retained  as  the  simplest 
and  most  accurate  test  of  ventilation  in  inhabitated  rooms. 
It  serves  as  an  index  of  the  conditions  that  are  deleterious. 

Test  for  CO2  method  of  Cohen  and  Appleyard,  recom- 
mended by  the  laboratory  section  of  the  American  PubUc 
Health  Association. 

Principle  of  Method.— Lime-wsiter  colored  with  phenol- 
phthalein  if  brought  in  contact  with  air  containing  more 
than  enough  CO2  to  combine  with  all  the  Ume  will  become 
decolorized  by  the  excess  of  CO2,  and  this  is  a  time  reaction. 

Application.— CoWect  samples  of  air  in  J-Hter  glass-stop- 
pered bottles.  Run  in  10  c.c.  standard  lime-water  solution 
and  note  the  time.  Shake  bottle  vigorously  until  color  dis- 
appears, and  note  time  and  estimate  amount  of  CO2  frora 
the  following  table: 


THE 

CAMP 

Time  in  minutes. 

CO2  per  10,000. 

Time  in  minutes. 

CO2 

per  10,000 

li 

16.0 

3^ 

6.0 

li 

13-8 

4 

5 

3 

I* 

12.8 

4l 

5 

I 

2 

12.0 

5, 

4 

6 

2i 

II-5 

5i 

4 

4 

2f 

8.6 

61 

4 

2 

3i 

7-7 

7J 

3 

5 

65 


Standard  Lime-water. — To  a  liter  of  distilled  water  add 
2.5  c.c.  of  phenolphthalein  (0.7  gm.  phenolphthalein  in  50 
c.c.  alcohol  plus  50  c.c.  water).  Stand  bottle  on  a  piece  of 
white  paper  and  add,  drop  by  drop,  saturated  lime-water 
until  a  faint  color  persists  for  a  full  minute.  Now  add  6.3 
c.c.  of  saturated  lime-water  and  quickly  cork  the  bottle. 

Amount  of  Air  Required. — This  has  always  been  based  on 
keeping  the  amount  of  CO2  down  to  the  permissible  limit  of 
6  parts  per  10,000,  i.  ^.,  3  parts  as  normal  constituent  of  air 
and  3  parts  as  the  result  of  contamination.  Here,  again,  it 
should  be  remembered  that  this  is  merely  an  index  of  other 
conditions  that  are  deleterious. 

It  is  usually  calculated  that  each  person  should  receive 
per  hour  3000  feet  of  fresh  air  in  a  steady,  even  manner, 
without  draught  or  perceptible  change  of  temperature. 
Experience  shows  that  when  the  amount  of  air  per  hour 
introduced  into  a  room  is  more  than  three  or  four  times  its 
cubic  capacity  a  current  becomes  perceptible.  The  capacity 
allowed  each  man  should  be  at  least  750  cubic  feet. 

Floor  Space. — The  amount  allowed  each  man  should  never 
be  less  than  60  square  feet  and  80  square  feet  is  much  better 
(See  note  on  Overcrowding.)  This  with  a  12-foot  ceiling 
would  allow  each  man  960  cubic  feet. 

Practical  Rule  for  Ventilating  Inlets  and  Outlets. — A  good, 
practical  rule  is  to  give  each  person  no  less  than  30  square 
inches ;  this  with  a  velocity  -of  two  feet  per  second  will  deliver 
1500  cubic  feet  per  hour.  This  artificial  ventilation  is  never 
reUed  on  exclusively,  but  is  supplemented  by  natural  venti- 


66 


SANITATION  FOR  MEDICAL  OFFICERS 


lation.    A  better  distribution  of  air  is  obtained  by  providing 
small  and  numerous  inlets  rather  than  few  and  large. 

Inspection  for  Bad  Ventilation. — To  determine  whether 
ventilation  is  satisfactory  a  medical  officer  should  inspect 
barracks  in  the  early  hours  of  the  morning  when  the  air  is 


Fig.   7. — Ventilation  of  tents.     (Lewis  and  Miller.) 


at  its  worst.  The  carbon  dioxide  test  may  be  made  to  obtain 
accurate  records,  but  for  practical  purposes  this  is  not  neces- 
sary. On  entering  from  the  fresh  outside  air  the  nose  is 
very  sensitive  to  stagnant  air  and  bad  odors  and  is  a  suffi- 
ciently accurate  guide  for  practical  work. 

Ventilation  of  Tents. — In  cold  weather  there  is  a  tendency 
to  close  all  air  holes  in  a  tent.._  On  the  border  last  winter 


THE  CAMP 


67 


when  Sibley  stoves  were  installed  a  metal  hood  with  a  hole 
through  the  side  to  accommodate  the  stove  pipe  was  substi- 
tuted for  the  canvas  hood  on  all  pyramidal  tents.  An  order 
was  ispued  requiring  this  hood  to  be  raised  4  inches  above  the 


CROSS  SECTION  A-B 
Fig.  8. — Hot-water  apparatus.     (From  Truby,  in  the  Military  Surgeon.) 

canvas.  This  arrangement  gives  protection  from  the  rain 
and  at  the  same  time  ensures  a  certain  amount  of  ventilation. 
Bathing. — In  permanent  camps  bathing  and  laundry  facili- 
ties should  be  provided ;  the  sanitary  officer  should  assure  him- 
self that  these  facilities  are  used  and  operate  satisfactorily. 


68  SANITATION  FOR  MEDICAL  OFFICERS 

In  semipermanent  camps  care  must  be  taken  that  the  wash 
water  is  disposed  of  in  a  proper  way  and  that  the  ground  does 
not  become  soiled  with  these  wastes.  Troughs  are  often 
built  where  the  men  can  place  their  wash  basins,  and  unless 
care  is  exercised  these  basins  will  be  emptied  upon  the 
surrounding  ground,  which  soon  becomes  muddy  and  filthy. 
Where  there  are  no  sewer  facilities,  as  in  temporary  camps, 
this  waste  water  can  be  disposed  of  in  soakage  pits.  These 
are  simply  deep  pits  that  are  filled  with  stones  of  various 
sizes,  and  the  top  covered  with  sod  except  for  a  small  opening 
several  feet  square  where  the  waste  water  is  poured.  Such 
pits  do  not  function  well  in  a  clay  soil. 

Hot  Water. — Hot  water  is  almost  essential,  especially  for 
washing  greasy  dishes  and  mess  kits.  In  permanent  camps  j 
provision  for  hot  water  will  be  made,  but  in  semipermanent 
camps  there  is  often  no  provision  except  the  company  stove 
which  will  usually  be  wanted  for  other  purposes.  Whenever 
camps  are  sufficiently  permanent  to  build  incinerators, 
advantage  may  be  taken  of  this  apparatus  to  provide  hot  \ 
water.  Thus  an  iron  tank  may  be  built  into  the  incinerator 
just  beyond  the  smoke  stack  where  the  hot  gases  of  combus- 
tion must  pass.  The  following  device  described  by  Major 
Truby  in  the  Military  Surgeon  is  excellent,  and  such  an 
apparatus  will  provide  a  plentiful  supply  of  hot  water  for 
dishes  and  for  a  number  of  baths  daily. 

One  ij-inch  pipe  of  galvanized  iron  leads  from  the  bottom 
of  an  ordinary  water  barrel,  through  the  fire-box  of  the 
kitchen  incinerator  and  back  again  to  the  barrel.  The 
return  pipe  enters  the  barrel  about  8  inches  above  the 
bottom.  The  pipes  from  the  barrel  pass  horizontally 
through  one  of  the  side  walls  of  the  incinerator,  and  across 
the  whole  width  of  the  fire-box  just  beneath  the  evaporating 
pan.  The  barrel  may  be  connected  with  the  supply  pipe 
from  the  water  main  if  desirable.  I 

Materials   Required. — i  piece  pipe,  5  feet  long;   i    piece 


THE  CAMP  69 

pipe,  4 J  feet  long;  3  pieces  pipe,  8  inches  long;  4  elbows; 
4  lock  nuts;  i  tap  for  drawing  off  water. 

RECREATION. 

■  The  subject  of  recreation  is  generally  ignored  in  books 
dealing  with  practical  sanitation,  possibly  because  it  is 
assumed  that  recreation  wdll  be  spontaneous  if  the  soldier  is 
left  to  his  own  devices,  and  that  there  is  no  occasion  for  the 
sanitary  officer  to  concern  himself  on  this  point. 

Experience  indicates  that  this  view  is  fallacious.  The 
soldier  when  left  to  himself  too  often  Ues  about  in  utter  bore- 
dom or  seeks  a  neighboring  town,  where  he  falls  a  wilUng 
victim  to  "wine,  women  and  song,"  not  so  much  because  of 
inherent  evil  tendencies  as  because  of  his  utter  inability  to 
amuse  himself  in  more  legitimate  ways. 

It  is  ordinarily  considered  that  the  provision  of  recreation 
is  a  function  of  the  chaplain,  and  when  a  chaplain  of  the 
right  type  is  present,  this  matter  may  be  safely  left  in  his 
hands,  although  he  should  receive  the  cordial  support  of 
medical  officers  in  his  efforts.  When  a  chaplain  is  not  pres- 
ent, medical  officers  should  consider  this  work  as  a  part  of 
their  sanitary  duties,  for  it  is  one  of  the  immutable  laws  of 
human  nature  that  certain  periods  of  recreation  are  neces- 
jsary  if  good  work  is  to  be  performed.  And  if  the  recreation 
is  provided,  the  men  will  not  only  perform  their  duties  with 
'greater  zest,  but  in  many  cases  will  be  saved  from  drunken- 
ness and  venereal  disease  when  all  the  preachments  of  the 
chaplain,  the  lectures  of  the  sanitary  officer  and  the  orders  of 
the  commanding  officer  fail. 

In  a  permanent  camp  there  should  be  a  Ubrary  for  all  who 
enjoy  reading,  and  moving  pictures  should  be  shown  fre- 
quently. Interest  in  games,  both  athletic  and  otherwise, 
should  be  stimulated,  and  every  effort  should  be  made  to 
provide  the  men  with  legitimate  occupation. 

When  soldiers  are  on  active  duty  at  the  front  their  minds 


70  SANITATION  FOR  MEDICAL  OFFICERS 

are  fully  occupied  too  often  by  no  pleasing  sights  and  sounds. 
When  they  return  to  the  rear  for  a  period  of  recuperation  it 
is  especially  important  that  recreation-  of  an  active  kind  be 
provided  to  prevent  an  idle  mind  from  brooding  upon  past 
experiences.  This  is  a  fertile  cause  of  neurasthenia  and  men- 
tal strain.  Lelean,  in  Sanitation  in  War,  says:  *'The  tension 
of  actual  danger  serves  as  a  stimulus  which  carries  men  with 
credit  through  the  experiences  in  the  trench  itself.  The 
inevitable  mental  reaction  is  proportionate  to  the  temporary 
exaltation,  and  return  to  billets  is  followed  by  depression  of 
which  only  the  highly  strung  man  knows  the  full  intensity. ' 
In  the  enforced  inaction  of  the  forty-eight  hours  rest  before 
duty  again  calls  his  unit  to  the  trenches,  scenes  of  horror 
which  were  only  subconsciously  perceived  during  the  stress 
of  action  emerge  with  vivid  persistence,  and  the  unceasing 
boom  of  the  enemy's  guns  keeps  memory  perpetually  alert. 
As  the  hours  of  respite  from  the  imminence  of  violent  death 
slip  by,  men  who  recall  their  own  hair-breadth  escapes  and 
note  the  empty  places  of  many  a  comrade  can  but  speculate 
involuntarily  upon  the  odds  against  their  own  escape  from 
dangers  constantly  renewed.  The  higher  moral  courage  car- 
ries them  through  the  effort  of  dissimulation,  but  the  effort 
is  a  costly  one  in  mental  strain.  To  what  practical  conclu- 
sion does  this  consideration  lead?  That  every  effort  must 
be  made  to  pro\dde  our  men  with  occupation  which  will  fill 
this  period  of  suspense  so  full  of  other  interests  that  there 
will  be  no  leisure  for  brooding  or  anticipation,  while  relaxa- 
tion of  all  tension  gives  the  opportunity  for  recuperative 
mental  rest." 

It  should  be  noted  in  this  connection  that  the  Army 
Young  Men's  Christian  Association  has  been  accorded  an 
ofhcial  status  by  Circular  15,  1904,  W.  D.,  and  G.  O.  39, 
19 14.  These  orders  provide  that  suitable  sites  will  be  selected 
and  assigned  for  the  tents  of  the  association,  and  that  the 
equipment  of  the  association  will  be  transported  when  means 
are  available. 


THE  CAMP  71 

PHYSICAL  TRAINING. 

The  recruit  is  generally  an  untrained  man  and  is  usually 
incapable  of  sustaining  the  strain  of  marching  with  his  equip- 
ment. While  in  camp  he  must  therefore  be  trained  to  march 
and  also  to  use  the  arms  with  w^hich  he  is  provided.  Although 
this  training  is  necessarily  executed  by  line  officers,  the  medical 
officer  should  be  familiar  with  the  principles  of  physical 
training,  and  should  be  on  guard  to  see  that  the  men  are  not 
injured  by  being  required  to  perform  exercises  beyond  their 
limit  of  endurance.  Undue  fatigue  does  not  strengthen  but 
weakens,  and  may  result  in  serious  injury,  particularly  to 
the  heart. 

The  objects  to  he  accomplished  by  physical  training  are: 

1 .  The  loss  of  excess  fat  and  the  hardening  and  strengthen- 
ing of  the  muscles. 

2.  Coordination. — The  muscles  and  nervous  system  of  the 
untrained  man  are  incoordinated,  and  as  a  result  he  expends 
far  more  energy  than  the  trained  man  in  performing  the  same 
amount  of  work.  The  trained  swimmer  slips  through  the 
water  much  more  easily  than  the  novice  by  the  expenditure 
of  a  trifle  of  the  energy  dissipated  by  the  latter.  The  same 
principle  applies  equally  to  marching.  Marching  is  not  the 
same  thing  as  w^alking.  In  addition  to  carrying  a  load,  the 
marching  soldier  must  walk  at  a  prescribed  gait  which  is 
often  not  his  customary  gait.  This  brings  entirely  new  sets 
of  muscles  into  action,  and  training  is  therefore  required 
for  efficient  marching  quite  as  much  as  for  efficient  swimming. 

3.  The  Training  of  the  Heart  Muscle. — When  the  untrained 
man  exerts  himself  the  heart  is  too  weak  to  maintain  the 
increased  blood  flow  required,  and  as  the  blood-pressure  is 
increased  by  exercise,  there  is  a  tendency  for  the  heart  to 
become  distended.  If  exertion  is  too  severe  this  may  cause 
actual  dilatation.  With  training  the  heart,  like  the  other 
muscles,  becomes  competent  to  perform  the  increased  work. 

4.  Training  the  respiratory  system  to  eliminate  rapidly 


72  SANITATION  FOR  MEDICAL  OFFICERS 

the  waste  products  which  result  from  muscular  action  and 
which  produce  shortness  of  breath  and  fatigue  when  they 
accumulate. 

Exercises. — All  exercises  tend  to  accomplish  the  objects 
enumerated  under  the  first,  third  and  fourth  headings,  but 
coordination  can  only  be  secured  by  training  in  the  particular 
exercise  in  which  skill  is  required.  Marching  will  not  perfect 
a  man  in  bayonet  drill  and  vice  versa.  Therefore  the  only 
way  to  train  a  man  to  march  is  to  march.  All  exercises  should 
be  carefully  graduated  so  as  to  avoid  undue  fatigue  at  any 
time,  and  should  be  made  as  varied  and  interesting  as  possible. 
Light  exercises  frequently  repeated  are  of  much  more  value 
than  heavy,  continuous  exercise.  The  time  devoted  to 
exercise  should  not  exceed  five  hours  daily — three  in  the 
morning  and  two  in  the  afternoon — and  no  exercises  should 
be  held  immediately  following  a  meal.  In  accordance  with 
these  principles  marches  should  at  first  be  easy  and  without 
packs.  The  length  of  the  march  should  be  progressively 
increased,  and  when  sufficiently  trained  and  hardened  the 
men  should  march  with  the  full  pack.  Before  marching 
particular  attention  should  be  paid  to  the  fitting  of  soldiers' 
shoes  and  socks,  and  they  should  be  instructed  in  the  care  of 
the  feet.  See  G.  O.  No.  26,  W.  D.,  191 2.  (This  order  is 
included  under  notes  on  the  March.) 

Danger  Signs. — Any  sign  of  enlargement  of  the  heart,  a 
weak  or  irregular  pulse,  or  a  pulse  that  does  not  return  to 
normal  within  an  hour  after  exercise,  indicates  that  the 
particular  exercise  was  too  severe.  Constant  lassitude, 
impaired  appetite  and  digestion  and  loss  of  weight  and 
strength  indicate  that  the  exercises  are  being  overdone  and 
that  the  men  are  becoming  overtrained. 

Soldier's  Heart.— This  term  has  been  used  to  describ< 
the  various  functional  cardiac  disorders  especially  commor 
among  soldiers  both  during  the  period  of  training  and  par- 
ticukirly  while  on  active  service.    It  is  most  commonly  duf 


THE  CAMP  73 

to  the  effect  of  overexertion  which  may  be  associated  with 
mental  strain  and  msufficient  sleep  or  with  some  form  of 
toxemia,  more  particularly  the  excessive  use  of  tobacco. 

Symptoms. — Very  moderate  exercise  which  should  not  hurt 
anyone  produces  shortness  of  breath,  giddiness,  faintness  and 
exhaustion.  More  violent  exercise  produces  dyspnea  and 
palpitation.  Discomfort  or  pain  in  tTie  region  of  the  heart, 
with  palpitation,  tachycardia  and  neurasthenic  condition 
are  generally  present.  If  a  diagnosis  of  valvular  disease  be 
made,  this  increases  the  neurasthenia.  The  pulse  may  be 
normal  at  rest  but  the  sHghtest  exertion  accelerates  it. 

The  blood-pressure  is  normal  or  low.  There  is  usually  some 
dilatation  on  both  sides  of  the  heart,  but  especially  on  the 
right  side.  Murmurs  may  be  present  and  may  lead  to  a 
diagnosis  of  valvular  disease,  but  these  murmurs  are  always 
systoHc  and  tend  to  disappear  as  the  condition  improves, 
while  there  is  no  history  of  rheumatism  or  endocarditis  or 
other  condition  that  would  cause  valvular  trouble. 

Treatment. — Assure  the  patient  that  he  will  recover  to 
!  reHeve  his  mind  and  prevent  neurasthenia  from  developing. 
Compel  rest  in  bed  until  the  dilatation  is  entirely  gone. 
Thereafter  the  patient  must  take  graduated  exercises  just 
insufficient  to  cause  exhaustion,  dyspnea,  or  pain.    The  man 
I  should  not  be  sent  to  duty  until  he  can  do  a  full  day's  work, 
[which  may  require  from  three  weeks  to  a  year's  treatment, 
1  depending  on  the  severity  of  the  condition.    Most  cases  can 
be  returned  to  duty  if  carefully  managed,  but  a  few,  especially 
those  of  generally  poor  physique,  wdll  probably  have  to  be 
discharged  on  a  certificate  of  disabihty. 
ji     Prophylaxis. — The  avoidance  of  undue  strains  by  untrained 
'men:  It  would  seem  almost  axiomatic  that  all  men  should 
not  be  subjected  to  exactly  the  same  exercises.    Those  exer- 
cises that  can  be  performed  with  ease  by  a  man  accustomed 
to  manual  labor  or  athletic  exercises  may  prove  exhausting 
to  the  student  or  clerk  who  has  been  poHshing  a  chair  for 


74  SANITATION  FOR  MEDICAL  OFFICERS 

several  years.  Common-sense  therefore  indicates  that  in 
training  a  large  number  of  men  from  all  walks  of  life,  these 
men  should  be  divided  into  classes  so  that  exercises  may  be 
suited  to  their  various  abilities.  The  determination  of  the 
class  to  which  a  man  should  belong  would  naturally  be  made 
by  the  surgeon,  and  in  examining  a  man  for  this  purpose, 
Pignet's  index,  taken  in  conjunction  with  muscular  develop- 
ment and  past  occupation,  should  afford  a  good  guide. 

Pignet's  Formula  for  Estimating  Physical  Effi- 
ciency.— The  weight  in  kilograms  and  the  chest  measure  at 
expiration  in  centimeters  are  added  and  subtracted  from  the 
height  in  centimeters. 

Index  of  Efficiency. — 

Under  lo Very  strong 

From  10  to  15 Strong 

15  to  20 Good 

20  to  25 Fair 

25  to  30 Weak 

30  to  35 Very  weak 

Above  35 .-     .  Useless 

In  order  to  use  this  formula  which  has  been  very  widely 
applied  in  calculating  physical  efficiency,  it  is  necessary  to 
translate  our  inches  and  pounds  into  the  metric  system. 
Inches  divided  by  0.3937  equals  centimeters.  Pounds 
di\dded  by  2.2046  equals  kilograms. 

Examples. — A  man  5  feet  8  inches  in  height  (172.7  cm.), 
36  inches  chest  (91.4  cm.),  and  152  pounds  (69  kilo).  69 
plus  91.4  from  172.7  equals  12.3  or  strong. 

A  man  5  feet  10  inches  in  height  (177.8  cm.),  34  inches 
chest  (86.3  cm.),  and  140  pounds  weight  (63.6  kilos).  63.6 
plus  86.3  from  177.8  equals  27.9  or  weak. 

To  determine  the  average  or  normal  weight  of  any  man, 
Bernhardt's  formula  may  be  used. 


THE  CAMP  75 

Height  in  cm.  X  chest  circtimference  in  cm.  ^^^-^j^^  -^^  ^^^^ 

240 

It  is  to  be  noted  that  the  ideal  weight  or  the  weight  that 
indicates  the  greatest  expectation  of  hfe  has  been  found  by 
life  insurance  companies  to  be  quite  different  from  the  normal 
or  average  weight.  In  individuals  under  twenty-five  years 
the  ideal  weight  is  usually  above  the  average  and  in  individuals 
over  thirty-five  years  of  age  the  ideal  weight  is  below  the 
average. 

VENEREAL  PROPHYLAXIS. 

G.  O.  No.  17,  W.  D.,  Washington,  May  31,  1912.  i.  It  is 
enjoined  upon  all  officers  serving  with  troops  to  do  their 
utmost  to  encourage  healthful  exercises  and  physical  recre- 
ation and  to  supply  opportunities  for  cleanly  social  and 
interesting  mental  occupations  for  the  men  under  their  com- 
mand; to  take  advantage  of  favorable  opportunities  to  point 
out,  particularly  to  the  younger  men,  the  inevitable  misery 
and  'disaster  which  follow  upon  intemperance  and  moral 
uncleanliness,  and  that  venereal  disease,  which  is  almost  sure 
to  follow  licentious  Hving,  is  never  a  trivial  affair.  Although 
the  chief  obligation  and  responsibihty  for  the  instruction  of 
soldiers  in  these  matters  rests  upon  company  officers,  the 
medical  officers  should  cooperate  by  occasional  lectures  or 
other  instruction  upon  the  subject  of  sexual  physiology  and 
hygiene  and  the  dangers  of  venereal  infection. 

2.  Commanding  officers  will  require  that  men  who  expose 
themselves  to  the  danger  of  contracting  venereal  disease  shall 
at  once  upon  their  return  to  camp  or  garrison  report  to  the 
hospital  or  dispensary  for  the  application  of  such  cleansing 
and  prophylaxis  as  may  be  prescribed  by  the  Surgeon-General. 
Any  soldier  who  fails  to  comply  with  such  instructions,  if 
found  to  be  suffering  from  a  venereal  affection,  shah  be 
i  brought  to  trial  by  court-martial  for  neglect  of  duty. 


76  SANITATION  FOR  MEDICAL  OFFICERS 

3.  Commanding  officers  will  require  a  medical  officer, 
accompanied  by  the  company  or  detachment  commander, 
to  make  a  thorough  physical  inspection  twice  in  each  month 
of  all  the  enlisted  men  (except  married  men  of  good  character) 
of  each  organization  belonging  to  or  attached  to  the  command. 
These  inspections  will  be  made  at  times  not  known  beforehand 
to  the  men  and  preferably  immediately  after  a  formation. 
The  dates  on  which  the  physical  inspections  of  the  various 
organizations  are  made  will  be  noted  on  the  monthly  sanitary 
reports. 

At  these  inspections  a  careful  examination  of  the  feet  and 
footwear  and  of  the  condition  of  personal  cleanliness  of  the 
men  will  be  made,  as  well  as  careful  observ^ation  for  the  detec- 
tion of  venereal  diseases. 

Cases  of  the  latter  will  be  promptly  subjected  to  treatment, 
but  not  necessarily  excused  from  duty  unless,  in  the  opinion 
of  the  surgeon,  deemed  desirable.  They  will  be  made  of 
record  in  the  medical  reports  in  any  case.  A  Hst  of  those 
diseased  but  doing  duty  will  be  kept  both  by  the  company  or 
detachment  commander  and  the  surgeon,  and  the  infected 
men  will  be  required  to  report  to  a  medical  officer  for  system- 
atic treatment  until  cured.  While  in  the  infectious  stages 
the  men  should  be  confined  strictly  to  the  limits  of  the  post. 
When  a  venereal  case,  whether  or  not  on  sick  report,  is  trans- 
ferred to  another  command,  the  surgeon  will  send  a  transfer 
slip  giving  a  brief  history  of  the  case. 

4.  All  instructions  from  the  War  Department  prohibiting 
the  publication  in  printed  or  other  orders  of  instructions  pre- 
scribing examinations  having  in  view  the  detection  of  venereal 
diseases  among  enlisted  men,  heretofore  issued,  are  recalled. 

[1915426,  A.  G.  O.] 

By  order  of  the  Secretary  of  War: 

Leonard  Wood, 

Official'  Major-General,  Chief  of  Staff. 

W.  p.  Hall, 

Adjutant-General. 


THE  CAMP  77 

Confidential  Circular  to  Medical  Officers:  W.  D.,  Office 
of  the  Surgeon- General,  Washington,  June,  191 2.  The 
following  directions  for  carrying  out  the  system  of  venereal 
prophylaxis  directed  by  par.  2,  G.  O.  17,  W.  D.,  1912,  are 
pubHshed  for  the  information  and  guidance  of  medical  officers : 

A  suitable,  easily  accessible  room  in  the  hospital  (or  dis- 
pensary) at  each  post  will  be  selected  for  this  purpose,  which 
should  be  provided  with  a  good  light  and  such  medical  sup- 
plies, basins,  and  other  equipment  as  may  be  necessary.  A 
competent,  properly  instructed  man  of  the  Hospital  Corps,  or 
more  when  necessary,  will  be  on  duty  there  between  retreat 
and  reveille,  and  will  be  within  call  at  other  hours. 

The  procedure  in  the  case  of  men  reporting  for  treatment 
will  be  as  follows: 

1.  The  name,  rank,  and  organization  of  the  soldier,  with 
the  day  and  hour  of  treatment  should  be  entered  for  record 
on  a  card  furnished  for  the  purpose,  which  will  afterward 
be  examined  and  authenticated  by  the  initials  of  a  medical 
officer.  These  records  should  be  regarded  as  confidential 
and  should  be  kept  in  a  secure  place  and  not  shown  to  un- 
authorized persons  or  except  upon  proper  authority.  They 
will  not  be  preserved  longer  than  three  months. 

2.  The  genital  organs  will  be  thoroughly  washed  with  soap 
and  warm  water. 

3.  An  injection  will  be  made  into  the  urethra  of  4  c.c.  of 
the  standard  solution  of  2  per  cent,  protargol  dissolved  in 
glycerin  15  parts,  water  85  parts.  This  should  be  retained  in 
the  urethra  for  three  minutes.  In  individual  cases  when  the 
protargol  solution  is  found  to  produce  an  irritating  effect,  a 

'    20  per  cent,  solution  of  argyrol  may  be  used.    Other  solutions 
:   or  modifications  of  these  solutions  will  not  be  used  for  routine 

administration. 
i       4.  The  entire  penis  will  be  rubbed  with  calomel  ointment 
\    (30  per  cent,  in  benzoated  lard),  care  being  taken  that  the 
\  folds  of  the  prepuce  and  about  the  frenum  are  thoroughly 


78  SANITATION  FOR  MEDICAL  OFFICERS 

covered.  If  any  pimples  or  abrasions  exist  about  the  scrotum 
or  the  pubic  region,  these  should  also  receive  an  application 
of  the  ointment. 

The  parts  should  be  then  wTapped  in  a  napkin  of  soft 
paper  furnished  for  the  purpose,  in  order  to  protect  the 
clothing. 

A  record  of  each  prophylactic  treatment  should  be  kept 
on  the  Venereal  Prophylaxis  card,  form  77,  IVU  M.  D. 


THE  MARCH. 


The  general  principles  concerning  the  conduct  of  marches^ 
are  given  in  paragraphs  96-114  F.  S.  R.,  1914,  with  which 
all  medical  officers  should  be  familiar. 

It  is  advisable  to  begin  the  march  slowly  until  the  body 
is  warmed  to  the  point  at  which  muscular  action  is  most 
efficient.  This  will  generally  be  accompHshed  after  march- 
ing about  a  mile.  It  is  also  well  to  slow  the  pace  at  the  end 
of  the  march  in  order  to  avoid  going  into  camp  while  heated 
and  perspiring.  In  ho:  weather  the  shirt  should  be  open  to 
permit  free  evaporation  of  perspiration,  and  the  column 
should  be  kept  as  open  as  possible  in  order  to  afford  each 
man  plenty  of  air  and  access  to  the  cooling  breeze.  Halts 
should  preferably  be  made  on  dry  ground  sheltered  from  the 
sun  in  summer  and  from  the  wind  in  winter,  and  should  not 
be  long  enough  to  permit  the  muscles  to  become  stiff. 

Weight  to  be  Carried. — The  maximum  that  a  soldier 
can  carry  without  serious  loss  of  efficiency  is  30  per  cent,  of 
his  body  weight.  A  man  of  150  pounds  can  therefore  carry 
45  pounds.  With  the  present  pack,  the  weight  of  the  full 
equipment  is  40  pounds  5  ounces;  of  the  marching  equip- 
ment, 31  pounds  4  ounces,  and  of  the  fighting  equipment 
39  pounds  I  ounce.  When  transportation  is  available,  part 
of  the  equipment  should  be  carried  on  the  wagons. 

Fit  of  Shoes  and  Care  of  Feet. — ^The  abihty  of  a  man 
to  march  depends  very  largely  upon  the  condition  of  his  feet, 
and  when  the  feet  are  disabled  it  is  usually  because  of  badly 
fitting  socks  or  shoes.  The  following  order,  if  strictly  com- 
plied mth,  will  eliminate  most  foot  troubles. 

(79) 


80 


SANITATION  FOR  MEDICAL  OFFICERS 


G.  O.  No.  26,  W.  D.,  Washington,  August  16,  191 2.  With 
a  view  to  increasing  the  marching  capacity  of  troops,  com- 
pany commanders  will  personally  measure  the  feet  and  fit 
the  shoes  of  men  of  their  commands  and  will  be  held  respon- 
sible that  the  instructions  herein  contained  are  strictly 
followed. 


Fig.  9.. — Showing  how  to  take  measurements  for  the  fitting  of  shoes. 

(War  Department.) 

All  measurements  prescribed  herein  will  be  taken  \\ith 
the  soldier  standing  in  bare  feet  and  with  a  40-pound  burden 
on  his  back,  bearing  the  entire  weight  upon  the  foot  to  be 
measured.  Balance  may  be  preserved  by  resting  the  hand 
on  a  fixed  object.  The  measurements  of  the  foot,  which 
must  be  taken  to  make  suitable  preHminary  selection  of  the 
shoe  to  try  on,  are  (a)  the  length,  (b)  the  circumference 
around  the  ball. 

To  measure  the  length  the  soldier  will  stand  with  foot 
upon  the  foot  measure,  furnished  by  the  Quartermaster's 


THE  MARCH  81 

Department,  fitted  in  a  slot  in  a  board,  the  heel  of  the  sol- 
dier fitting  snugly  against  the  heel  block.  The  movable 
block  will  then  be  pushed  up  until  it  touches  the  end  of  the 
great  toe.  The  scale  on  the  top  of  the  measure,  which  is 
graduated  in  sizes,  will  then  be  read,  and  the  proper  length 
of  the  shoe  will  be  determined,  approximately,  by  adding  2 
to  the  reading  of  the  scale;  thus,  if  the  soldier's  foot  scales 
6i,  a  shoe  not  smaller  than  8 J  should  be  tried  on  first. 

To  take  the  ball  measure,  pass  the  foot  tape,  supplied  by 
the  Quartermaster's  Department,  around  the  foot  at  the 
prominent  tubercle  at  the  base  of  the  great  toe  and  the 
prominent  tubercle  at  the  base  of  the  little  toe.  The  position 
of  the  tape  is  shown  by  the  line  A-B  in  Fig.  9. 

The  tape  should  lie  closely  to  the  flesh,  but  should  not  be 
so  tight  as  to  compress  it.  Having  taken  the  foregoing 
measurements,  the  shoe  best  suited  to  the  foot  will  be  deter- 
mined by  reference  to  Circular  No.  10,  Quartermaster  Gen- 
eral's Office,  April  6,  191 2.  For  example,  assume  that  the 
circumference  of  the  ball  is  found  to  be  g\  inches.  In  the 
table  on  page  28  of  the  aforesaid  circular,  under  the  heading 
"Marching  Shoes,"  it  will  be  seen  that  for  a  foot  requiring 
an  8j  shoe  a  ball  measurement  of  9^  inches  corresponds  to 
a  D  width.  The  size  of  shoe  to  try  on  for  actual  fitting  is, 
then,  in  this  case,  8 J  D. 

If  the  ball  measurement  found  as  above  does  not  corre- 
spond exactly  with  any  ball  measurement  given  in  the  table, 
then  the  narrower  of  the  two  widths  between  which  the 
measurement  lies  should  be  selected. 

Beginning  with  the  size  and  width  thus  tentatively  selected, 
shoes  will  be  tried  on  until  a  satisfactory  fit  is  secured.  Cor- 
rect fit  in  waist  and  instep  will  be  determined  experimen- 
tally. To  determine  the  fact  of  fit  the  shoe  will  be  laced 
snugly  and  the  soldier  with  a  40-pound  burden  upon  his 
back  will  again  throw  his  entire  weight  on  one  foot.  The 
officer  will  then  press  in  the  leather  of  the  shoe  in  front  of 
6 


82  SANITATION  FOR  MEDICAL  OFFICERS 

the  toes  to  determine  the  existence  of  sufficient  vacant 
space  in  that  region  to  prevent  toe  injury.  Under  no  circum- 
stances should  this  vacant  space  in  front  of  the  great  toe  be 
less  than  two- thirds  inch;  nor  should  there  be  pressure  on 
the  top  of  the  toes.  The  officer  will  then  grasp  with  his 
hand  the  leather  of  the  shoe  over  the  ball.  As  his  fingers 
and  thumb  are  brought  slowly  together  over  the  leather,  the 
shoe  should  feel  snugly  filled  without  apparent  tension,  while 
the  leather  should  lie  smoothly  under  the  hand.  If  the 
leather  wrinkles  under  the  grasp  of  the  hand,  the  shoe  is 
too  wide  and  a  narrower  width  is  needed;  if  the  leather 
seems  tense  and  bulging  and  the  hand  tends  to  slip  over 
easily,  the  shoe  is  too  narrow  and  a  greater  wddth  is 
necessary. 

It  may  be  necessary  to  try  on  several  pairs  of  shoes  in  this 
manner  before  an  entirely  satisfactory  shoe  is  secured.  A 
record  of  the  proper  size  and  width  of  shoes  as  determined 
above  will  be  kept  as  provided  in  Circular  No.  lo,  Quarter- 
master General's  Office,  April  6,  191 2. 

Measurements  will  be  taken  and  shoes  will  be  fitted  as 
prescribed  at  least  once  in  each  enlistment  and  the  record 
will  be  changed  from  time  to  time  if  subsequent  fittings  render 
a  change  necessary. 

Sizes  called  for  in  requisitions  will  conform  to  the  record 
and  the  fact  of  fit  of  shoes  issued  on  such  requisitions  will  be 
personally  verified  in  every  instance  by  company  com- 
manders in  the  manner  above  prescribed. 

No  shoes  will  be  issued  to,  or  worn  by,  enlisted  men  while 
on  duty  which  are  not  fitted  in  accordance  with  this  order. 

New  shoes  should  be  adapted  to  the  contours  of  the  feet 
as  soon  as  possible.  Shoe  stretchers,  with  adjustable  knobs, 
to  take  pressure  off  painful  corns  and  bunions,  are  issued  by 
the  Quartermaster's  Department. 

All  shoes  should  be  properly  broken  in  before  beginning  a 


THE  MARCH  83 

march,  but  if  this  is  impracticable,  then  the  following  is 
suggested  but  not  required: 

The  soldier  stands  in  his  new  shoes  in  about  2J  inches  of 
water  for  about  five  minutes  until  the  leather  is  thoroughly 
pliable  and  moist ;  he  should  then  walk  for  about  an  hour  on 
a  level  surface,  letting  the  shoes  dry  on  his  feet,  to  the  irreg- 
ularities of  which  the  leather  is  thus  molded  in  the  same  way 
as  it  was  previously  molded  over  the  shoe  last.  On  taking 
the  shoes  off  a  very  Uttle  neat's  foot  oil  should  be  rubbed 
into  the  leather  to  prevent  its  hardening  and  cracking. 

If  it  is  desired  to  water-proof  the  shoes  at  any  time,  a 
considerable  amount  of  neat's  foot  oil  should  be  rubbed  into 
the  leather. 

Light  woolen  or  heavy  woolen  socks  will  habitually  be 
worn  for  marching;  the  socks  will  be  large  enough  to  permit 
free  movement  of  the  toes,  but  not  so  loose  as  to  permit  of 
wrinkling.  Darned  socks,  or  socks  with  holes,  will  not  be 
worn  in  marching. 

Company  commanders,  by  frequent  inspections  through- 
out the  year,  will  maintain  the  feet  of  their  men  in  condition 
for  proper  marching.  They  will  cause  the  proper  trimming 
of  nails,  removal  or  paring  of  corns  and  callouses,  relief  of 
painful  bunions,  treatment  of  ingrowing  nails,  and  other 
defects,  sending  serious  cases  to  the  surgeon. 

Before  a  march  is  undertaken  by  foot  troops  company 
commanders  will  personally  inspect  the  bare  feet  of  their 
men.  While  on  the  march  they  will  personally  see  each  day 
that  their  men  wash  their  feet  as  soon  as  possible  after 
reaching  camp,  prick  and  evacuate  blisters,  and  cover  such 
bhsters  or  excoriations  with  zinc  oxide  plaster,  supplied  by 
the  Medical  Department,  apphed  hot,  dust  the  feet  with 
the  foot  powder  supplied  by  the  Medical  Department,  and 
put  on  clean  socks.  Hereafter  an  undue  amount  of  foot 
injury  and  disabiHty  from  shoes  will  be  regarded  as  e\ddence 


84  SANITATION  FOR  MEDICAL  OFFICERS 

of  inefficiency  on  the  part  of  the  officers  concerned  and  as 
causes  for  investigation. 

Post  quartermasters  will  provide  a  place  in  the  quarter- 
master's storehouse  where  shoes  may  be  fitted  for  the  purpose 
of  determining  or  verifying  the  record  required  by  G.  O. 
No.  48,  W.  D.,  191 1.  For  the  purpose  of  fitting  they  will 
keep  on  hand  at  all  times  a  complete  series  of  each  size  and 
width  of  shoes  furnished  for  issue.  Shoes  of  this  series  will 
be  put  in  stock  and  issued  before  they  become  unservice- 
able, and  will  be  replaced  by  new  shoes,  keeping  the  series 
always  complete.  Company  commanders  will  report  in 
writing  to  the  post  commander  every  instance  of  failure  to 
secure  proper  shoes  for  their  commands  or  to  obtain  proper 
facihties  for  fitting  the  shoes  as  herein  directed.  Post  com- 
manders will  investigate  the  reasons  for  and  be  held  respon- 
sible as  far  as  lies  in  their  power  for  the  rectification  of  such 
deficiencies. 

A  brief  record  of  the  number  of  such  reports  from  company 
commanders  and  the  reason  for  such  deficiencies  will  be; 
furnished  to  inspectors  at  each  inspection  of  the  post. 

Inspections  conducted  under  the  provisions  of  paragraph 
913,  Army  Regulations,  will  embrace  an  inquiry  into  the 
manner  in  which  this  order  has  been  compHed  with,  and  the 
report  of  inspections  will  include  a  statement  of  all  instances 
of  failure  on  the  part  of  company  commanders  to  secure 
proper  shoes  for  their  commands  and  the  cause  of  such 
failure. 

[1856626  S— A.  G.  o.] 

By  order  of  the  Secretary  of  War: 

Leonard  Wood, 

Major-General,  Chief  of  Staff. 

Official: 

Geo.  Andrews, 

Adjutant-General. 


THE  MARCH  85 

Water  Supply  on  the  March. — The  amount  of  water 
required  by  a  man  depends  upon  certain  physiological  prin- 
ciples. 

1.  The  exercise  of  marching,  like  all  general  muscular 
exercise,  produces  an  elevation  of  the  body  temperature  of 
from  2  to  3°  F. — that  is,  to  between  100.4°  a,nd  101.4°  F. 

2.  This  rise  is  physiological,  beneficial,  and  in  fact  neces- 
sary to  the  efficient  performance  of  muscular  w^ork. 

3.  This  elevated  temperature  is  the  normal  for  the  condi- 
tion of  active  exercise,  just  as  98.4°  is  the  normal  for  rest. 
:  4.  The  temperature  is  kept  at  this  constant  level  by  three 
methods  of  heat  loss,  radiation,  convection,  and  evaporation 
of  perspiration. 

5.  The  marching  soldier  is  chiefly  dependent  on  evapora- 
tion of  perspiration  for  the  regulation  of  bodily  tempera- 
ture, especially  on  warm  days,  when  the  surrounding  air  is 
not  much  if  any  cooler  than  the  body. 

6.  The  body  contains  a  considerable  amount  of  water  and 
cannot  lose  more  than  a  certain  amount  without  loss  of  effi- 
ciency. Therefore  the  regulation  of  the  temperature  by 
evaporation  necessitates  a  replacement  of  the  w^ater  lost. 

The  question  of  water  supply  on  the  march  therefore 
resolves  itself  into  two  questions,  namely.  How  much  water 
can  the  body  afford  to  lose,  and  w^hen  and  how  often  must 
this  water  be  replaced? 

How  much  water  can  the  body  afford  to  lose?  A  man 
weighing  150  pounds  contains  in  his  tissues  100  pounds  oi 
water.  He  cannot  afford  to  lose  more  than  one-tenth  of  this, 
that  is,  10  pounds  or  i  gallon,  without  endangering  his  life. 
If  a  man  is  in  good  condition  and  well  trained,  he  can  perhaps 
afford  to  lose  7.5  pounds,  or  6  pints,  without  loss  of  effi- 
ciency or  great  suffering;  while  if  in  bad  training,  a  loss  of 
2  pints  mil  impair  efficiency  and  cause  discomfort.  These 
quantities  represent  the  upper  and  lower  limits  of  permis- 
sible loss.     But  whether  the  limit  of  permissible  loss  be  high 


86  SANITATION  FOR  MEDICAL  OFFICERS 

or  low  it  must  be  emphasized  that  once  this  limit  has  been 
reached  the  lost  water  must  be  steadily  replaced.  From  this 
time  on  all  water  lost  through  evaporation  must  be  replaced 
to  avoid  loss  of  efficiency,  suffering,  or  even  death. 

How  much  water  will  a  man  lose  in  marching  a  given  dis- 
tance? The  actual  exertion  demanded  by  a  march  of  one 
mile  over  undulating  country  may  be  estimated  as  90  gram 
calories  for  a  soldier  with  full  equipment.  If  the  heat  thus 
produced  is  to  be  dissipated  by  evaporation,  then  for  every 
mile  180  c.c.  of  water  must  be  evaporated.  In  one  hour's 
march,  covering  three  miles  and  allowing  a  ten-minute  halt 
in  the  hour,  the  soldier  will  have  lost  540  c.c.  or  almost  a 
pint  (570  c.c).  But  for  the  first  mile  the  heat  produced  will 
be  utilized  in  raising  his  bodily  temperature  to  the  optimum 
for  exercise,  and  heat  regulation  will  not  come  into  play 
until  this  distance  has  been  covered.  We  may  estimate 
therefore  that  at  the  end  of  the  first  four  miles  he  will  have 
lost  I  pint,  at  the  end  of  seven  miles  nearly  2  pints,  the 
amount  fixed  as  the  lower  limit  of  possible  loss.  In  the  case 
of  the  untrained  man  we  may  therefore  assume  that  he  should 
be  able  to  march  seven  miles,  or  half  an  ordinary  day's  march 
without  drinking.  At  the  half-way  halt  he  must  have  his 
first  drink,  and  after  that  i  pint  of  water  regularly  every 
hour  during  the  march.  The  canteen  contains  about  i  quart, 
of  which  I  pint  may  be  taken  after  covering  seven  miles  at 
the  half-way  halt  and  the  remainder  at  the  end  of  ten  miles, 
after  w^hich  he  should  be  able  to  cover  the  remainder  of  the 
fourteen  miles  and  get  home  without  any  further  supply. 
However,  if  the  road  be  a  hard  one,  hilly,  muddy,  or  the  day 
unusually  warm,  this  estimate  will  not  hold  and  more  water 
must  be  supplied.  If  the  march  be  continued  beyond  ordinary 
limits,  as  in  a  forced  march,  then  every  man  must  have  his 
pint  of  water  every  hour  after  the  limit  of  endurance  is 
reached.  It  is  on  the  recognition  of  this  fact  that  the  effi- 
cient performance  of  forced  marches  depends. 


THE  MARCH  87 

We  may  conclude  therefore: 

1.  A  soldier  on  the  march,  even  if  untrained,  should  be 
able  to  cover  the  first  half  of  the  march,  that  is  seven  miles, 
without  a  drink. 

2.  That  at  the  half-way  halt  of  an  ordinary  march  he 
should  be  allowed  to  drink  half  the  contents  of  his  water 
bottle  and  the  remainder  at  the  next  hourly  halt. 

3.  If  a  march  is  over  fourteen  miles  wdth  raw  troops  or 
over  twenty  with  any,  the  staff  should  make  careful  plans 
for  the  watering  of  the  men  at  the  rate  of  i  pint  per  man  per 
hour,  or  per  three  miles,  as  long  as  the  march  lasts.  The 
necessity  of  replacing  the  water  regularly  hour  by  hour  may 
be  emphasized.  A  double  allowance  at  longer  intervals 
does  not  answer  the  purpose  so  well,  although  of  course  it 
might  be  unavoidable.  Water  after  ingestion  is  only  slowly 
taken  up  by  the  tissues,  and  if  there  is  any  excess  it  merely 
passes  through  the  kidneys  without  doing  the  body  much 
good  so  far  as  heat  regulation  is  concerned.  Water  supply 
must  be  regular  and  sufficient,  and  must  never  be  left  to 
chance  any  more  than  the  supply  of  ammunition  may  be 
left  to  chance. 

Officers  who  can  get  along  with  less  water  than  this  should 
remember  that  they  rarely  carry  the  same  weight  as  the  men, 
and  therefore  not  only  perform  less  work  in  marching  the 
same  distance,  but  also  that  they  are  able  to  regulate  the 
heat  much  better  because  evaporation  from  the  skin  is  not 
impeded  by  the  equipment,  and  because  they  do  not  march 
in  the  ranks  where  the  air  is  close,  but  on  the  outskirts 
where  they  catch  all  the  breeze. 

The  quaUty  of  the  water  obtained  is  a  most  important 
thing,  and  every  effort  must  be  made  to  secure  w^ater  of  the 
proper  quality  for  the  men.  But  is  must  be  remembered  that 
a  certain  quantity  is  absolutely  indispensable  if  life  is  to  be 
maintained,  and  that  the  appetite  for  water,  after  the  body 
has  become  depleted  to  the  limit  of  permissible  loss,  is  a  most 


88  SANITATION  FOR  MEDICAL  OFFICERS 

imperious  demand.  We  may  as  well  expect  a  starving  dog 
to  abstain  from  a  piece  of  meat  as  to  expect  the  marching 
soldier  to  abstain  from  water  under  these  circumstances. 
The  only  way  to  prevent  soldiers  from  drinking  water  from 
improper  sources  is  to  see  that  they  are  supplied  with  a  suffi- 
cient quantity  from  a  pure  source.^ 

To  Estimate  the  Amount  of  Water  Delivered  by  Streams. — 
The  sectional  area  may  be  estimated  by  the  average  depth. 
The  velocity  may  be  estimated  as  four-fifths  of  the  surface 
velocity,  as  shown  by  the  time  it  takes  a  stick  to  pass  a 
known  distance.  The  number  of  cubic  feet  passing  a  certain 
sectional  area  in  a  given  time  is  thus  ascertained.  This  may 
be  converted  into  gallons  by  multiplying  by  the  factor  6.23. 

Hot  Water  for  Marching  Commands. — When  men  are  on  the 
march  for  more  than  a  day  at  a  time  their  mess  kits  become 
filthy  unless  some  provision  is  made  for  washing  them.  Often 
the  soldier  will  simply  scrub  them  out  with  grass  or  dead 
leaves.  Grease  can  only  be  removed  by  washing  with  hot 
water.  The  sanitary  officer  should  therefore  see  that  it  is 
provided  and  used.  As  soon  as  the  meal  is  cooked,  water 
should  be  placed  on  the  stove  by  the  cook,  and  the  knives, 
spoons,  and  meat  cans  can  be  washed  in  this.  Each  man 
washes  his  own,  and  as  men  do  not  finish  eating  all  at  once, 
the  washing  need  cause  little  delay.  If  possible  the  w^ater  may 
be  heated  much  hotter  by  placing  it  on  the  fire  while  the  meal 
is  in  preparation. 

The  Purification  of  Water  in  the  Field. — Unless  the 
water  supply  has  been  pronounced  safe  by  the  sanitary- 
officer  it  must  be  purified  before  use.  The  following  methods 
are  recommended  in  the  order  given: 

The  Lyster  Water-bag. — An  appliance  carried  on  the  supply 
table  as  water-bag,  field  steriUzing,  and  is  an  adaptation 
of  the  principle  of  steriUzation  by  chlorin,  to  the  needs  of 

^  This  note  is  largely  an  abstract  of  an  article  by  Col.  C.  H.  Melville, 
R.  A.  M.  C.  Water  Supply  on  the  March. 


THE  MARCH  89 

troops  in  the  field.  It  consists  of  a  canvas  bag,  20  inches  in 
diameter  and  28  inches  in  length,  sewn  to  a  flat  galvanized 
iron  ring  which  is  hinged  so  that  it  folds.  Spliced  at  four 
equidistant  poixits  on  the  ring  are  tw^o  crossed  pieces  of  hemp 
rope,  enabling  the  bag  to  be  suspended  on  any  convenient 
support  capable  of  holding  the  weight  of  the  bag  when  filled 
with  water,  which  is  about  330  pounds.  Five  nickel,  spring 
faucets  are  placed  at  equal  spaces  about  the  bottom  edge  of 
the  bag.  The  neck  of  these  faucets  is  small  enough  to  enter 
a  canteen,  which  can  be  filled  in  ten  seconds.  The  self-closing 
faucets  prevent  wastage.  The  bag  provides  a  receptacle  in 
which  water  can  be  held  long  enough  to  sterilize  it  and  then 
distribute  it.  After  the  bag  is  suspended  and  filled  with 
water  (30  gallons)  it  is  sterilized  by  the  addition  of  calcium 
hypochlorite.  This  is  carried  in  measured  doses  sealed  in  glass 
tubes.  A  package  of  sixty  of  these  tubes  weighs  10  ounces 
and  measures  yj  by  3J  by  4}  inches.  Packed  in  corrugated 
paper  it  wdll  stand  rough  usage.  The  tubes  themselves  are 
3  inches  in  length  by  f  of  an  inch  in  diameter  and  are  marked 
with  a  file,  enabling  them  to  be  easily  broken  in  the  fingers 
without  fragments.  They  contain  from  14  to  15  grains  of 
calcium  hypochlorite.  This  chemical  contains  from  30  to  32 
per  cent,  of  chlorin,  which  forms  hypochlorous  acid  in  the 
water,  thus  sterilizing  it.  In  the  strength  used  even  waters 
that  are  highly  infected  are  rendered  safe,  and  all  ordinary 
waters  will  be  entirely  safe  after  this  treatment.  Experiments 
have  indicated  that  the  organisms  causing  typhoid  and  dysen- 
tery are  destroyed  by  this  treatment  after  fifteen  minutes. 
In  the  field  after  the  water  has  been  treated  it  should  be 
allowed  to  remain  in  the  bag  for  from  fifteen  to  thirty  minutes, 
when  it  may  be  drawn  and  used.  This  treatment  will  not 
remove  suspended  matters.  In  order  to  remove  these  a  filter 
cloth  to  be  fastened  over  the  opening  of  the  bag,  and  weighing 
I  ounce  is  provided,  or  the  water  may  be  strained  through  a 
blanket.  One  bag  will  supply  sufi&cient  pure  water  for  a 
company. 


90  SANITATION  FOR  MEDICAL  OFFICERS 

A  Method  of  Titration  to  Determine  the  Amount  of  Chlorin 
Actually  Needed  for  Sterilization  of  Water. — It  is  possible  that 
even  in  hermetically  sealed  tubes  the  calcium  hypochlorite 
may  undergo  decomposition  with  a  loss  of  the  available 
chlorin.  Moreover,  the  amount  used  (i  part  to  500,000 
parts  of  water)  is  ordinarily  excessive,  since  it  has  been  found 
that  I  part  of  chlorin  to  7,000,000  parts  of  water  will  kill 
all  bacteria,  providing  the  water  is  free  of  organic  matter. 
On  the  other  hand,  it  is  possible,  though  not  probable,  that  if 
the  water  contained  a  great  excess  of  organic  matter  the 
amount  of  chlorin  furnished  in  one  of  the  tubes  might  be 
insufficient  to  sterilize  the  water.  For  all  of  these  reasons  it 
is  desirable  to  titrate  the  w^ater  to  be  treated  in  order  to  deter- 
mine the  amount  of  chlorin  that  will  be  required.  A  simple 
method  for  this  purpose  was  described  by  Professor  G.  Sims 
Woodhead  in  the  British  Medical  Journal,  September  19, 
1914,  ii,  494,  and  this  method  is  being  used  at  present  by 
the  British  troops  in  France.  The  following  method  is  the 
same  as  that  described  by  Professor  Woodhead,  except  that 
it  has  been  adapted  to  our  own  service  utensils : 

1.  Rinse  a  regular  ordnance  cup  (supplied  with  each 
canteen  and  holding  i  pint  or  500  c.c.)  with  water,  leaving  a 
few  drops  of  water  in  the  cup.  Break  one  of  the  tubes  of 
calcium  hypochlorite  into  the  cup  and  mix  it  into  a  paste 
with  the  few  drops  of  water.  As  soon  as  the  powder  is 
thoroughly  moistened,  fill  the  cup  with  water  (500  c.c.)  to 
within  one  inch  of  the  top  and  mix  well  by  pouring  into 
another  cup  and  then  back.  Part  of  this  solution  is  used  in 
titrating  the  water  to  be  sterilized  and  the  remainder  is  used 
for  sterilizing  the  water.  This  solution  contains  0.3  gram  of 
available  chlorin. 

2.  Rinse  four  ordnance  cups  with  the  water  to  be  tested  and 
fill  all  four  cups  to  one  inch  from  the  top  with  the  water  to  be 
tested.  With  a  pipette  (a  hypodermic  syringe  may  be  used) 
add  0.2  c.c.  of  the  calcium  hypochlorite  solution  to  the  first 


THE  MARCH  91 

cup  of  water;  add  0.4  c.c.  to  the  second  cup;  add  0.6  c.c. 
to  the  third  cup;  add  0.8  c.c.  to  the  fourth  cup.  Mix  the 
solution  with  the  water  in  each  cup  by  pouring  it  back  and 
forth  into  another  cup  and  allow  the  cups  to  stand  for  thirty 
minutes  (fifteen  minutes  if  time  is  important). 

3.  Into  a  clean  cup  crumble  a  potassium  iodide  tablet  or 
drop  a  few  crystals  of  potassium  iodide,  and  add  a  tablet  of 
soluble  starch  or  a  httle  starch  solution  made  by  boiling 
cornstarch  in  water  for  a  few  minutes.  Pour  into  this  cup 
the  water  to  which  was  added  0.8  c.c.  of  the  calcium  hypo- 
chlorite solution  (cup  4)  and  mix  by  pouring  back  and 
forth.  If  a  blue  color  appears  it  is  an  indication  that  the 
chlorin  has  not  been  all  used  up  in  that  mixture.  It  should  be 
pointed  out  that  this  blue  color  is  not  permanent  and  dis- 
appears in  a  few  minutes.  In  the  same  way  mix  potassium 
iodide  and  soluble  starch  with  the  samples  of  cups  3,  2 
and  I.  The  cup  that  contains  the  smallest  amount  of  the 
hypochlorite  solution  capable  of  giving  a  blue  color  with  the 
potassium  iodide  and  starch  contains  the  proportion  of 
chlorin  necessary  to  sterilize  the  water  being  tested.  Thus 
suppose  the  cup  of  water  to  which  0.4  c.c.  of  the  hypochlorite 
solution  was  added  gives  a  blue  color  with  the  potassium 
iodide  and  starch  and  the  sample  to  which  0.2  c.c.  of  the 
solution  was  added  gives  no  color.  The  sample  to  which 
0.4  c.c.  of  the  hypochlorite  solution  was  added  contains  the 
right  amount  of  chlorin  to  sterihze  the  water  being  tested. 

There  are  36  gallons,  or  288  pints,  in  the  water-bag.  Since 
0.4  c.c.  of  the  hypochlorite  solution  was  sufficient  to  sterilize 
one  pint,  115  c.c.  of  the  same  solution  will  be  sufficient  to 
sterilize  the  288  points  in  the  Lyster  bag.  The  pint  of  hypo- 
chlorite solution  already  prepared  would  therefore  be  capable 
of  sterilizing  more  than  three  bags  of  water.  In  practice, 
however,  it  is  believed  to  be  safer  to  use  twice  the  amount 
indicated  by  the  titration,  so  that  in  the  example  quoted 
230  c.c.  of  the  hypochlorite  solution  would  actually  be  added 


f 

92  SANITATION  FOR  MEDICAL  OFFICERS 

to  the  water  to  be  treated,  or  half  of  the  solution  (250  c.c.) 
could  be  added  to  the  water  in  one  bag  and  the  solution 
prepared  from  the  tube  of  calcium  hypochlorite  would  be 
sufficient  to  sterihze  two  bags  of  water. 

While  the  adoption  of  this  method  will  cause  a  little  trouble, 
it  is  believed  that  the  results  obtained  will  be  satisfactory, 
since  the  great  excess  of  chlorin  at  present  being  used  will  be 
reduced  and  the  water  thereby  rendered  more  palatable. 
The  method  is  being  used  at  the  front  by  the  British  service, 
which  is  suppHed  with  tablets  of  potassium  iodide  and  soluble 
starch  prepared  by  Parke,  Davis  &  Co. 

The  Darnall  Filter. — Should  the  Lyster  bag  not  be  avail- 
able this  apparatus  may  be  used.  This  is  an  adaptation  of  the 
principle  of  mechanical  filtration  to  the  needs  of  troops  in 
the  field.  It  consists  of  a  galvanized  iron  tank,  two  water 
cans,  and  a  siphon  filter  and  cloth  crated.  The  essential 
part  is  the  cylindrical  metal  framework  of  the  siphon,  over 
which  is  wrapped  the  filtering  material,  a  closely  woven 
cotton  fabric.  This  is  placed  in  the  tank  filled  with  raw  water 
to  which  the  precipitant  has  already  been  added,  and  the 
water  after  passing  through  the  filtering  cloth  into  the 
cylinder  is  discharged  by  siphonage  into  the  water  can.  As 
matters  in  suspension  deposit  upon  the  cloth  the  flow 
diminishes,  and  the  filter  should  be  taken  out  and  the  cloth 
removed  and  cleaned  by  washing  and  sterilized  by  boiling 
water.  The  precipitant  consists  of  alum  and  sodium  carbon- 
ate in  such  proportions  that  they  neutralize  each  other. 
This  precipitant  is  furnished  in  a  small  tin  can  with  a  measure 
which  holds  2  grams.  The  water  cans  when  filled  to  the 
mark  hold  3  gallons.  One  measure  of  the  precipitant  added 
to  each  can  of  raw  water  is  sufficient  for  even  grossly 
polluted  waters. 

The  crated  filter  weighs  52  pounds  and  will  deliver  about 
200  gallons  of  water  in  four  hours.  It  completely  clarifies 
the  water,  and  its  bacterial  efficiency  is  about  98  per  cent. 


THE  MARCH  93 

This  apparatus  cannot  be  depended  upon  for  the  certain 
elimination  of  all  pathogenic  bacteria,  but  it  purifies  ordinary 
waters  to  a  degree  that  renders  them  reasonably  safe.  It 
will  furnish  plenty  of  clear  water  unchanged  in  temperature 
and  taste  within  an  hour  after  getting  into  camp.  One  filter 
may  be  carried  by  each  company  in  the  field. 

Boiled  Water. — Should  neither  of  these  appUancesbe  at 
hand  an  impure  water  should  be  boiled.  A  quartermaster 
G.  I.  can  is  filled  with  water  which  is  left  on  the  fire  until  it 
boils.  The  water  is  then  cooled  and  used.  Soldiers  do  not 
like  boiled  water  because  of  its  flat  taste,  and  should  this 
method  be  used  it  must  be  closely  supervised  by  medical 
officers  to  be  sure  the  water  is  actually  boiled,  and  that  this  is 
used  rather  than  the  raw  water.  Boiled  water  is  absolutely 
safe,  as  none  of  the  pathogenic  organisms  causing  the  various 
intestinal  diseases  can  stand  boiling  temperature.  The 
objections  to  its  use  are  that  it  is  troublesome,  requires  a  long 
time  after  reaching  camp  before  the  water  is  ready  for  use, 
requires  fuel  which  is  sometimes  unavailable,  and  the  great 
dislike  of  the  men  for  the  use  of  boiled  water,  which  renders 
it  certain  that  some  of  them  will  drink  the  water  raw. 

Latrines. — Latrines  for  Moving  Commands. — Colonel  Har- 
vard's knock-down  box  consists  of  eight  pieces  which  are 
standardized  and  interchangeable  with  those  of  any  other 
box,  and  weighs  175  pounds.  It  is  put  together  without  screws 
or  bolts,  and  can  easily  be  taken  apart  and  packed  in  a  wagon 
when  there  is  plenty  of  transportation.  If  it  is  possible  to 
carry  it  this  box  is  very  convenient  and  far  more  sanitary 
than  the  open  pit  generally  used  with  marching  commands. 

Joneses  Improvised  Incinerator. — Major  Percy  Jones  has 
described  an  incinerator  that  can  be  improvised  anywhere. 
A  pit  is  dug,  preferably  in  a  hillside,  2 J  feet  deep,  2  feet  wide, 
and  4i  feet  long,  with  back  and  floor  of  brick  or  stone  with 
or  without  mortar.  If  the  camp  is  only  for  a  day  or  two  the 
stone  is  unnecessary.    One  foot  below  the  top  the  sides  have 


94  SANITATION  FOR  MEDICAL  OFFICERS 

projecting  shoulders  upon  which  are  placed  two  of  the  McCall 
excreta  pans  or  an  improvised  substitute;  if  used  only  for 
one  night,  w^ooden  pans  may  be  used,  which  are  burned  with 
the  excreta.  A  good  fire  is  built  under  this  once  daily  and  all 
excreta  are  consumed.  Urine  cans  may  be  emptied  inter- 
mittently on  the  heated  stones.  This  pit  should  be  covered 
over  with  a  temporary  boxed  seat  or  the  Havard  box,  in  order 
to  keep  out  the  flies.  Place  to  leeward  of  the  camp  as  it 
produces  an  unpleasant  odor  when  fired. 

Straddle  Trenches. — In  the  absence  of  any  special  device  or 
of  fuel  for  incineration,  straddle  trenches  are  often  used  by 
marching  commands.  Such  trenches  may  be  made  3  feet  long, 
I  foot  wide,  and  2  feet  deep,  each  trench  being  intended  to  be 
used  by  one  man  at  a  time.  The  dirt  is  heaped  up  at  the  end, 
not  at  the  side,  and  there  should  be  an  interval  of  3  feet 
between  trenches.  Five  trenches  are  provided  for  each  100 
men,  or  three  or  four  for  each  100  in  large  commands.  A 
scoop  should  be  provided  and  a  notice  posted  requiring 
each  man  to  cover  his  excreta  with  earth,  and  if  necessary  a 
sentry  may  be  posted  to  see  that  this  order  is  carried  out. 

Major  Patterson  has  described  a  straddle  trench  cover  that 
will  practically  do  for  these  trenches  what  is  accompKshed  by 
the  latrine  box  for  semipermanent  camps.  Two  planks, 
8  inches  wide  and  6  feet  8  inches  long,  are  nailed  10  inches 
apart  on  four  cross-pieces  of  2  by  4.  The  space  between  these 
is  closed  in  the  middle,  but  forms  an  opening  2  feet  long  on 
each  end  for  defecation.  A  hinged  cover  is  provided  for  each 
opening  which  falls  of  its  own  weight  and  keeps  the  pit  covered 
at  all  times  except  when  in  use.  This  device  being  light  can 
easily  be  carried  by  marching  commands. 


A" 


EMBARKATION. 


Sanitary  Measures  Prior  to  Embarkation. — Sanitary 
measures  should  be  taken,  with  a  view  to  interfering  as  little 
as  possible  with  the  movement  of  troops,  since  this  is  the 
all-important  military  objective.  Yet  so  far  as  possible  an 
attempt  must  be  made  to  remove  from  the  command  such 
cases  as  might  prove  infectious  aboard  ship,  where  the  men 
are  necessarily  somewhat  crowded.  Under  ideal  circum- 
stances daily  inspections  of  the  men  should  be  made  at  the 
home  camp  to  detect  infectious  diseases  and  vermin.  The 
men  should  then  be  sent  to  a  detention  camp  near  the  port 
of  embarkation,  where  they  should  remain  for  ten  days,  during 
which  time  careful  daily  inspections  should  be  made  under 
the  supervision  of  the  surgeon  of  the  port  of  embarkation. 
Under  this  system  it  should  be  possible  to  exclude  most 
infections  and  all  vermin.  When  this  is  not  possible, ^  an 
inspection  is  made  after  the  troops  are  detrained  and  just 
prior  to  embarkation.  The  general  orders  at  the  port  of 
embarkation  include  the  following: 

I.  Upon  the  receipt  of  orders  for  foreign  service,  or  upon 
the  receipt  of  orders  to  proceed  to  a  point  preliminary  to 
embarkation,  daily  physical  inspections  should  be  made  of  all 
enlisted  personnel  belonging  to  the  organizations  specified 
in  the  orders,  and  these  inspections  should  be  continued  daily 
until  the  troops  are  debarked  at  a  foreign  port.  Inspection 
should  be  made  by  the  medical  officers  on  duty  with  an 
organization,  and  one  or  more  will  be  assigned  to  this  duty 
under  the  direction  of  the  senior  medical  officer,  the  division 
surgeon  or  the  camp  surgeon,  as  the  case  may  be. 

(95) 


96  SANITATION  FOR  MEDICAL  OFFICERS 

2.  Medical  officers  will  observe  the  greatest  care  in  making 
these  inspections,  immediately  removing  from  the  organiza-. 
tion  all  cases,  or  suspected  cases,  of  communicable  disease. 
They  will  carefully  scrutinize  all  men,  watching  for  the  early 
signs  and  symptoms  of  disease  or  the  presence  of  vermin, 
and  will  not  be  satisfied  to  wait  until  the  condition  has 
fully  developed  before  making  diagnosis  and  taking  proper 
action. 

3.  Cases  of  communicable  disease  will  not  be  permitted  to 
proceed  to  port  of  embarkatiorh,  nor  will  known  contacts  of 
scarlet  fever,  cerebrospinal  meningitis  and  measles.  All  cases 
of  venereal  disease,  acute  or  chronic,  will  be  removed  from  the 
organizations. 

4.  Upon  arrival  at  the  port  of  embarkation,  or  e7i  route  to 
such  point,  a  final  examination  will  be  made  by  the  medical 
officers  representing  these  headquarters  and  under  the  direc- 
tion of  the  surgeon,  port  of  embarkation.  At  this  examination 
the  men  will  be  stripped  to  the  waist  and  carefully  examined 
for  signs  and  symptoms  of  venereal  as  well  as  other  communi- 
cable diseases,  including  vermin. 

5.  The  medical  officers  making  this  final  examination  will 
submit  a  report  to  the  surgeon,  these  headquarters,  showing 
the  presence,  if  any,  of  the  disease  in  question,  with  the  name, 
organization,  nature  of  disease,  date  of  last  previous  inspec-. 
tion  and  the  name  of  the  medical  officer  by  whom  it  was 
made,  and  stating  whether  in  the  opinion  of  the  medical 
officer  detecting  the  disease,  the  disease  was  present  at  the 
time  of  the  last  previous  inspection. 

10.  At  the  daily  inspections  of  troops  aboard  ship,  careful 
search  will  be  made  to  detect  the  presence  of  vermin,  espe- 
cially body  lice.  Cases  of  vermin  will  be  promptly  removed 
from  contact  with  others  until  they  shall  have  been  deloused. 
When  steam  sterilization  of  clothing  is  impracticable,  cloth- 
ing will  be  deloused  by  boiling,  immersion  in  gasoline  or 
kerosene,  or  ironing  with  a  hot  iron. 


EMBARKATION  97 

II.  The  physical  inspections  directed  in  this  order  will  be 
made  as  follows: 

(a)  Place  of  examination  will  be  warm  and  well  lighted; 
artificial  light  will  not  be  used  unless  absolutely  necessary. 

(b)  Men  will  be  stripped  to  the  waist  and  will  be  prepared 
to  lower  their  drawers  and  breeches  for  inspection  of  the 
genitals. 

(c)  The  parts  inspected  will  be  turned  toward  the  light 
and  as  near  a  window  as  practicable,  and  the  following  order 
followed : 

A.  Eyes,  noting  presence  of  conjunctivitis. 

B.  Nose,  noting  presence  of  coryza. 

C.  Parotid  glands,  noting  presence  of  swelling. 

D.  Mouth,  noting  presence  of  Koplik  spots,  congestion 
of  buccal  mucous  membranes,  rash  or  congestion  of  hard 
palate,  scarlet  tongue  or  mucous  patches. 

E.  Throat,  noting  presence  of  sore  throat  and  its  character. 

F.  Chest,  abdomen  and  back,  noting  presence  of  rash  or 
signs  of  vermin. 

G.  Genitals,  noting  presence  of  any  venereal  disease  or 
vermin. 

(d)  The  finding  of  any  of  the  suspicious  signs  will  be 
followed  by  a  more  careful  examination,  the  man  being 
questioned  as  to  exposure,  former  attack  of  the  disease,  his 
temperature  taken  and  such  laboratory  specimens  sent  to 
the  laboratory  as  the  case  demands. 

Lice. — ^The  head  and  pubic  hair  should  be  examined  for 
lice  or  nits.  The  presence  of  P.  vestimenti  may  often  be 
detected  by  the  signs  of  scratching  on  the  body;  but  as  the 
lice  live  chiefly  in  the  clothing,  the  articles  of  apparel  must 
be  examined.  This  may  be  done  by  directing  the  men  to 
turn  their  shirts  inside  out  and  carry  them  on  their  arms. 
The  seams  of  the  shirts  are  then  inspected,  and  when  the 
breeches  are  dropped  the  seams  of  the  underwear  and  breeches 
are  examined,  especially  at  the  crotch. 

7 


TRENCHES  AND  THE  BATTLEFIELD. 


SANITATION  OF  TRENCHES. 

The  average  trench  is  7  feet  deep  by  i  meter  wide,  and 
the  sides  are  lined  with  wooden  uprights  braced  by  cross- 
pieces. 

Trench  life  is  very  monotonous  and  trying.  On  the  Western 
front  the  men  occupied  trenches  for  three  or  four  days  in 
all  weathers,  and  were  then  relieved  for  a  period  of  recuper- 
ation. 


1st  LINE  FIRE  TRENCH 


L 


I 
o 

z 

HJ   Urine  Pit 


k[ 


SUPPORT  TRENCH 

z 


ffOs 


I 


< 
o 

z 

D 
S 

s 
o 


Bucket 
Urine  Pit 
Bucket 


Fig.  10 


Latrines. — Latrines  should  be  situated  in  dugouts  a 
short  distance  to  the  rear  of  the  trench,  and  connected 
with  the  latter  by  a  few  meters  of  the  connecting  trench, 
as  shown  in  Fig.  10.  The  dugout  should  be  deep  enough  to 
protect  against  any  missiles  except  high-explosive  shells. 
Here  a  pit  is  dug  and  covered  with  a  latrine  seat.  Incinera- 
tion is  impossible  for  lack  of  fuel,  and  because  it  would  give 
(98) 


TRENCHES  AND   THE  BATTLEFIELD 


99. 


IMPROVISED  LATRINE  FOR  FIRST-LINE  TRENCHES 

(FLY- proof) 

UD   HINGED    WITH    LEATHER 


DETACHABLE     SEAT 


SUPPORTS 
BACK  8f  <  ; 
FRONT     '^ 
^E£PING 
SEAT  FIRM 


METHOD     OF    REMOVAL 
FOR.    EMPTYING 


SECTION 


Fig.  ji. 


100  SANITATION  FOR  MEDICAL  OFFICERS 

t 

the  range  to  artillery.  The  method  adopted  has  been  to 
collect  excreta  in  small  buckets,  empty  gasoline  tins  and 
similar  receptacles.  These  are  tightly  covered  and  carried 
to  the  rear  by  the  troops  when  relieved  and  clean  cans  are 
brought  forAvard  and  put  in  place  by  the  new  troops.  The 
cans  containing  the  excreta  are  preferably  burned  in  an  incin- 
erator at  the  rear  when  fuel  is  available,  but  when  this  cannot 
be  done  the  cans  are  buried  in  deep  pits  and  well  covered. 
Lime  or  iron  sulphate  or  crude  oil  may  be  used  to  cover  the 
excreta.  Iron  sulphate  is  a  good  deodorant.  As  the  dugout  is 
lighted  only  by  a  candle  or  lantern,  flies  are  not  attracted  in 
great  numbers,  but  the  latrine  box  should  be  made  fly-tight. 

Urinals. — A  urine  absorption  pit  may  be  made  as  fol- 
lows: Fill  a  pit  of  4  to  6  feet  deep  and  4  feet  square  with 
stones  or  clinkers,  covering  over  the  top  with  sod  except  in 
the  middle,  where  a  tar-paper  funnel  or  a  biscuit  tin,  with 
perforated  bottom,  may  be  placed  to  act  as  a  funnel  for  the 
urine.  In  order  to  repel  flies,  crude  petroleum  should  be 
freely  used.  As  the  conveniences  just  described  require 
some  time  for  their  construction,  some  simple  device  must 
be  used  w^hen  a  trench  is  first  taken  or  constructed,  before  the 
latrine  pits  can  be  dug.  Fig.  11,  taken  from  Lelean,  indi- 
cates the  principle  on  which  these  improvised  latrines  are 
made. 

Water. — Water  and  food  must  be  carried  to  the  men. 
Water  may  be  carried  in  cans  and  should  be  sterilized  with 
calcium  hypochlorite.  The  Lyster  bag  may  be  used.  Food 
may  be  kept  warm  by  keeping  in  a  jacketted  hot  box,  con- 
structed on  the  principle  of  fireless  cookers.  A  tin  receptacle 
is  enclosed  in  a  box,  surrounded  by  a  2-inch  layer  of  chopped 
straw  or  sawdust.    This  will  retain  the  heat  for  a  long  time. 

Debris  and  Police. — AU  debris  must  be  collected  in  bags 
and  carried  to  the  rear  at  intervals.  No  food  should  be 
thrown  away  or  allowed  to  collect,  as  this  attracts  rats  and 
flies. 


TRENCHES  ANi)  THE  BATTLEFIELD  101 

Flies. — Flies  have  been  very  troublesome  in  France.  This 
is  caused  to  a  considerable  extent  by  the  dead  bodies  in 
front  of  the  trenches  in  "no  man's  land,"  and  as  this  con- 
dition cannot  be  prevented  in  trench  warfare,  flies  must  be 
present  and  measures  must  be  taken  against  them.  Fly 
poisons  may  be  used  if  there  is  no  other  place  for  them  to 
drink,  and  under  these  circumstances  will  be  very  effective; 
but  when  the  trenches  are  full  of  water,  but  little  can  be 
expected  of  this  measure.  Screening  should  be  used  whenever 
possible,  and  flies  must  be  kept  from  latrines  and  urinals. 
When  screening  is  unobtainable,  after  the  flies  have  been 
driven  out  of  the  latrine,  a  cloth  sprinkled  with  creosote  oil 
may  be  hung  over  the  places  where  they  may  enter.  By  this 
means  the  majority  of  flies  may  be  kept  from  entering  for 
several  days.  The  buckets  may  be  sprayed  with  the  same 
mixture.  Creosote  oil  may  also  be  used  on  dead  bodies  to 
prevent  the  development  of  flies.  (See  Note  on  Disposal  of 
Dead.)  Food  may  be  kept  in  small  screened  boxes,  or  a 
receptacle  may  be  improvised  as  follows:  Take  a  muslin 
bag  of  cylindrical  shape,  2  feet  wide  and  4  feet  long.  This 
bag  may  be  distended  with  hoops  of  metal  wires  or  wdthes, 
and  food  may  then  be  hung  in  this  bag,  which  is  tied  at 
the  top. 

I  Standing  Water. — Trenches  should  be  kept  free  from 
jitanding  water  by  means  of  hand  pumps,  and  whenever 
'Dossible  this  should  be  insisted  on  as  a  sanitary  measure. 
Standing  in  water  and  mud  predisposes  to  trench  foot  and 
iffords  an  opportunity  for  the  spread  of  other  diseases,  among 
ivhich  may  be  mentioned  acute  infectious  jaundice  (Weil's 
disease).  The  mud  ruins  the  clothes  and  equipment  and 
predisposes  to  the  various  w^ound  infections. 

Sleeping  Quarters. — Sleeping  quarters  should  be  built,  if 
Dossible,  in  small  wooden  dugouts  so  that  the  men  can  sleep 
vvarm  and  in  comfort.  Such  measures  add  greatly  to  the 
efficiency  of  the  men. 


102  SAI^ITATION  FOR  MED.^CAL  OFFICERS 

Washing. — It  is  not  to  be  expected  that  real  baths  can 
be  taken  in  the  trenches,  but  there  is  no  reason  why  some 
provision  cannot  be  made  for  washing.  A  reasonable  amount 
of  water  should  be  carried  to  the  trenches  for  washing,  and 
basins  may  be  provided.  An  absorption  pit  for  wash  water 
may  be  constructed  on  the  same  line  as  the  urine  absorp- 
tion pit.  The  British  troops  have  even  used  braziers  for 
heating  water  in  odd  tins  for  the  purpose  of  washing. 

Rats. — Rats  have  been  very  troublesome.  They  may  be 
reduced  to  a  minimum  by  using  the  greatest  care  that  there 
is  no  food  left  for  them.  They  may  be  killed  by  various 
rat  poisons,  by  traps,  or  terriers  may  be  taken  into  the 
trenches. 

Bathing  and  Delousing. — As  bathing  is  difficult  or  im- 
possible in  the  trenches,  it  is  essential  that  provision  for 
systematic  bathing  be  made  for  these  men  when  they  return 
to  camp  for  their  period  of  recuperation.  On  the  Western 
front  bathing  and  delousing  are  carried  out  with  the  division 
as  the  unit.  The  necessity  for  system  will  be  seen  when  it  is 
stated  that  i6o  men  must  be  bathed  and  deloused  per  hour 
for  nine  hours  a  day  if  each  man  in  the  division  is  to  receive 
a  bath  every  two  weeks.  This  is  certainly  not  an  excessive 
requirement,  and  bathing  must  at  least  be  as  frequent  as 
this.  Fig.  12  shows  one  of  the  plans  used  for  a  divisional 
bath  house,  in  which  ironing  of  the  clothes  is  relied  upon  to 
rid  them  of  lice.  The  addition  of  a  sterilizing  plant  would 
make  this  bath  house  an  efficient  delousing  station. 

Trench  Foot. — This  is  a  very  serious  condition  pro- 
voked by  moist  cold  and  complicated,  as  a  rule,  by  secondary 
infection.  The  condition  develops  in  four  stages  as  follows: 
(i)  painful  anesthesia;  (2)  edema;  (3)  phlyctenules;  (4) 
sloughing,  85  to  90  per  cent,  of  the  cases  are  slight,  charac- 
terized by  painful  anesthesia,  edema  and  redness;  13  to  14 
per  cent,  are  moderate,  with  phlyctenules  and  limited  sloughs; 
I  per  cent,  are  severe  cases  with  extensive  sloughs.    The  cause 


TRENCHES  AND  THE  BATTLEFIELD 


103 


appears  to  be  prolonged  exposure  to  a  low  temperature  not 
necessarily  near  the  freezing-point,  combined  with  wet,  and 


-20'- 


-3^ 


10 


11 


12 


IRONING  BOQM 


-1^ 


13 


14 


15 


16 


17 


18 


19 


o 


o 

r- 


STORE AND 

ISSUING  ROOM 
20^ 


20 

21 

CO 

LiJ 

I 

o 

22 

z 

UJ 

m 

23 

z 
O 
a: 

24 

25 

26 

16- 


-^J<- 


10 


11 


-M. 


UNDRESSING  ROOM 


27 

26 

25 

24 

23 

I  22 


CLEAN 


21 


20 


22 

23 

24 

25 

26 

10 

11 


DRESSING  ROOM 


19 


18 


17 


IG 


15 


14 


13 


12 


-40^ 


Pig.   12.5— From  Peacock,  The  Louse  Problem  on  the  Western  Front, 

British  Medical  Journal,  1916. 


blood  stasis  due  to  long  immobiUty,  compression  of  the  leg 
and  interference  with  the  venous  circulation.  Cases  of  trench 
foot  were  numerous  during  the  winter  of  1914-1915,  and 


104  SANITATION  FOR- MEDICAL  OFFICERS 

were  practically  limited  to  men  standing  in  water,  other 
troops  not  being  affected  to  any  extent.  When  for  any 
reason  the  stay  in  the  trenches  was  prolonged  for  several  days 
and  nights  consecutively  at  a  temperature  below  40°  F.,  men 
and  officers  often  became  incapacitated  for  several  months. 
The  most  aggravated  cases  occurred  in  men  who  had  been 
on  duty  several  days  without  removing  boots  or  puttees. 
Constriction  of  the  circulation  in  the  lower  limbs  is  therefore 
to  be  regarded  as  an  important  predisposing  cause,  and  this  is 
accentuated  by  wearing  tight  boots  or  shoes  combined  with 
prolonged  strain  in  the  standing  posture. 

Prophylaxis. — i.  Boots  and  shoes  should  not  fit  tightly, 
but  should  be  at  least  a  size  too  large.  When  boots  are  large 
enough,  two  pairs  of  socks  may  be  worn,  but  this  is  danger- 
ous if  the  shoes  are  too  small,  as  it  leads  to  further  pressure 
on  the  feet.  Never  use  puttees.  If  leggings  must  be  worn, 
some  other  type  must  be  supplied.  Rubber  hip  boots  should 
be  furnished  if  there  is  standing  water  in  the  trench. 

2.  The  general  circulation  must  be  kept  up  by  keeping 
the  body  warm  and  dry.  Wear  water-proof  coat  if  possible 
when  it  rains. 

3.  A  dry  pair  of  socks  should  be  carried  in  the  pocket, 
and  boots  should  be  removed  at  least  once  in  twenty-four 
hours,  the  feet  rubbed  and  dried  and  the  dry  socks  put  on. 
If  rubber  boots  are  not  available  the  boots  should  be  well 
greased  or  oiled. 

4.  Dry  standing  should  be  provided  whenever  possible. 
If  the  trench  cannot  be  pumped  out,  raise  the  foot  level  by 
fascines  of  brushwood  or  straw,  with  boards  on  top.  Avoid 
standing  still  as  much  as  possible.  When  unavoidable,  keep 
the  feet  moving. 

5.  Before  going  to  the  trenches  the  men  should  have  the 
feet  clean.  For  the  prevention  of  this  condition  special 
washing  booths  have  been  constructed  on  the  Western  front 
and  the  men  are  sent  by  companies  to  these  booths  just 


i 


TRENCHES  AND  THE  BATTLEFIELD  105 

before  going  to  the  trench.  They  wash  the  feet  thoroughly, 
dry  and  rub  them  well  and  finally  cover  with  a  foot  powder 
before  putting  on  socks  and  shoes.  After  this  treatment  the 
feet  remain  warm  for  several  hours,  and  ii  a  fungus  is  respon- 
sible this  treatment  tends  to  remove  it. 

Trench  Fever. — ^This  is  a  relapsing  fever  that  has  been 
very  prevalent  in  the  trenches  in  Europe  and  has  resulted 
in  considerable  impairment  of  efficiency,  although  there  have 
been  practically  no  fatal  cases. 

Etiology. — ^The  organism  that  produces  the  disease  is 
unknowTi.  It  is  not  filterable.  It  is  capable  of  withstanding 
drying  and  exposure  to  sunlight  for  at  least  sixteen  days. 
Heating  to  56°  C.  does  not  destroy  it,  but  heating  to  80°  C. 
for  ten  minutes  does  destroy  it. 

Method  of  Transmission. — Lice  infected  from  a  case  of 
trench  fever  gain  access  to  a  normal  individual.  The  bites 
are  scratched  and  excreta  or  crushed  lice  are  rubbed  into  the 
abrasion  produced  and  infection  follows.  This  has  been 
definitely  shown  by  a  British  Commission  {Jour.  Am.  Med. 
Assn.,  July  20,  1918,  p.  188).  It  was  shown  that  the  disease 
is  not  transmitted  by  the  bites  of  lice  per  se  but  that  it  was 
transmitted  by  rubbing  the  excreta  of  infected  lice  into 
excoriations.  The  virus  is  contained  -in  the  dried  excreta  of 
infected  lice  and  may  remain  in  the  clothes  for  a  considerable 
period.  Delousing  the  man  would  not  therefore  surely  pre- 
Ivent  the  disease  unless  the  clothing  is  disinfected  (heated 
to  80°  C).  Lice  that  have  never  bitten  cases  of  trench  fever 
'Cannot  transmit  the  disease  and  the  virus  is  not  transmitted 
to  the  young  lice  by  heredity.  It  was  shown  that  the 
(disease  could  not  be  produced  by  ingestion  or  inhalation  of 
Ithe  infected  excreta.  The  blood  of  a  patient  having  trench 
•fever  may  infect  lice  as  late  as  the  seventy-ninth  day  of  the 
[disease.  The  virus  appears  to  undergo  a  cycle  of  development 
;in  the  louse,  for  the  louse  is  not  infective  for  a  few  days  after 
it  has  bitten.    Excreta  from  such  lice  failed  to  produce  the 


106  SANITATION  FOR  MEDICAL  OFFICERS 

disease  for  the  first  six  days  but  produced  infection  from 
the  seventh  to  the  eleventh  day  after  feeding. 

Incubation  Period. — In  the  experimental  cases  this  was 
from  five  to  ten  days,  commonly  eight  days. 

Symptoms. — The  disease  generally  begins  suddenly  with 
severe  frontal  headache  followed  by  pain  in  the  lower  part 
of  the  back,  and  on  the  second  or  third  day  by  severe  pain 
in  the  legs.  The  bowels  are  regular  or  constipated  and  there 
is  no  bronchial  or  nasal  catarrh.  Tenderness  is  marked  over 
the  lower  half  of  the  shins  and  slight  pressure  here  may  cause 
great  pain,  though  the  muscles  are  not  particularly  hypersen- 
sitive. Leukocytosis  is  generally  present,  with  a  relative 
increase  in  the  large  mononuclear  cells.  There  are  two  types 
of  fever,  a  long  and  a  short  form. 

The  Short  Form. — The  temperature  rises  rapidly  to  between 
I02  °  and  104  °  F.  On  the  third  or  fourth  day  the  temperature 
falls  to  normal,  but  there  is  no  corresponding  improvement 
in  the  symptoms.  After  an  interval  of  a  few  hours  the  tem- 
perature rises  again,  and  then  after  an  interval  of  from  two 
to  five  days  it  falls  to  normal  again,  and  there  is  imme- 
diate relief,  and  the  patient  is  often  fit  for  duty  almost  at 
once. 

The  Long  Type. — Tlie  temperature  rises  to  between  101° 
and  104°  F.,  and  is  always  lower  in  the  morning  than  on  the 
preceding  and  following  evening,  the  highest  temperature 
being  reached  on  the  second  or  third  day.  The  first  attack 
may  last  four  or  five  days,  but  after  being  wxll  for  from  two 
to  ten  days  there  is  a  return  of  headache,  pain  in  the  legs, 
and  fever,  but  the  symptoms  are  less  severe  than  in  the 
first  attack.  Such  recurrences  follow  periodically  for  from 
four  to  six  weeks,  each  succeeding  attack  being  generally 
milder  than  its  predecessor  until  the  disease  apparently 
wears  itself  out. 

Diagnosis. — The  association  of  a  recurrent  pyrexia  with 
tender  shins  is  very  suggestive  of  trench  fever.    The  possi- 


TRENCHES  AND  THE  BATTLEFIELD  107 

bility  of  malaria  must  always  be  considered,  but  there  is  no 
definite  rigor,  quinine  has  no  effect,  and  of  course  malarial 
parasites  cannot  be  found.  In  some  cases  a  diagnosis  of 
influenza  was  made,  but  there  are  no  catarrhal  symptoms, 
and  the  definite  association  of  the  pain  in  the  bones  of  the 
leg  is  quite  different  from  influenza,  as  is  the  recurrent  nature 
of  the  fever. 

Treatment. — No  effective  treatment  has  been  found. 
Quinine  has  been  tried  but  gave  no  results.  Aspirin  and 
phenacetin  will  relieve  pain. 

Prophylaxis  appears  to  depend  upon  the  extermination 
of  lice.     (See  Typhus  Fever  and  Lice.) 

''Trench  Mouth." — This  was  formerly  unusual  but  may 
now  be  classed  as  a  common  disability  among  troops.  It  is  an 
infectious  ulceromembranous  stomatitis  and  gingivitis  (Vin- 
cent's disease).  The  condition  occurs  most  often  as  a  form 
of  tonsillitis,  but  it  also  causes  ulcers  on  the  lower  jaw  and 
along  the  margin  of  the  gums,  pyorrhea,  and  may  cause  a 
general  infection  of  the  entire  mouth. 

Etiology. — The  causal  organism  is  the  symbiotic  associa- 
tion of  the  spirillas  and  fusiform  bacilli  describes  by  Vincent 
in  what  is  now  known  as  "Vincent's  angina." 

Method  of  Transmission. — This  must  depend  upon  the 
transfer  of  infectious  saliva  from  the  infected  to  the  healthy, 
and  this  probably  occurs  most  often  by  indirect  contact,  as 
by  using  a  common  drinking  cup,  pipes,  eating  utensils,  etc. 

Prevention. — i.  Specific  Measures :  The  prompt  treatment 
of  all  infected.  Arsenic  is  highly  recommended  in  the  form 
of  arsphenamine  or  liquor  potassii  arsenitis  swabbed  on  several 
times  a  day.  Ulcers  may  be  treated  with  a  lo  per  cent,  solu- 
tion of  silver  nitrate. 

2.  General  Measures:  The  education  of  the  soldier  to 
the  point  where  he  will  not  put  any  object  in  his  mouth  that 
has  been  previously  in  another  person's  mouth.  The  disease 
has  probably  become  more  common  because  trench  warfare 


108  SANITATION  FOR  MEDICAL  OFFICERS 

naturally  tends  to  break  down  the  refinements  of  ordinary 
life. 

Trench  Nephritis  or  War  Nephritis. — The  frequency 
of  nephritis  among  men  on  duty  in  the  trenches  has  excited 
comment.  The  disease  has  apparently  prevailed  as  an 
epidemic  among  French  and  British  troops,  but  if  it  is  due 
to  an  infectious  agent  this  has  remained  undiscovered. 
The  inevitable  conditions  of  military  life  at  the  front  are 
predisposing  causes  if  not  the  determining  cause. 

The  most  marked  characteristic  of  this  form  of  nephritis 
is  its  relative  mildness  and  favorable  prognosis.  Edema  is 
the  most  constant  symptom,  but  soon  yields  to  rest  in  bed 
and  a  milk  diet.  There  may  be  vomiting,  headache,  and* 
lumbar  pain.  The  blood-pressure  is  increased.  There  is 
slight  albuminuria  associated  with  casts  and  red  blood  cells 
and  leukocytes.  In  some  instances  blood  is  present  in  the 
urine  in  sufficient  amount  to  discolor  it. 

HYGIENE  OF  THE  BATTLEFIELD. 

With  a  battle  impending: 

1.  Make  sure  of  the  presence  of  first-aid  packets  in  good 
condition. 

2.  Fill  canteen  with  water.  It  is  always  needed  by 
wounded.  Inspect  equipment  of  sanitary  personnel  to  be 
sure  they  have  ample  supplies  needed  for  first  aid. 

3.  See  that  the  men  are  as  clean  in  body  and  clothing  as 
the  circumstances  permit.  When  possible  wash  with  a  wet 
towel  and  put  on  clean  underclothing,  to  prevent  wound 
infection  as  far  as  possible. 

4.  Move  bowels  and  empty  bladder  to  avoid  extravasa- 
tion in  case  of  abdominal  injury.  Food  should  be  nourishing 
but  of  small  bulk. 

5.  If  injured,  the  men  should  be  taught  to  lie  still  at 
nearest  shelter  until  rescued.    A  shell  hole  affords  good  pro- 


i  TRENCHES  AND  THE  BATTLEFIELD  109 

i  tection.    Do  not  seek  shelter  of  underbrush,  as  wounded  may 

never  be  found  in  such  locations  if  unconscious. 
i      Disposal  of  Dead. — Bodies  may  be  stripped  of  outer 
'  clothing  to  promote   rapid   oxidation   and   prevent  putre- 
,  faction. 

I       Dig  a  pit  with  sloping  sides  35  feet  long,  7  feet  wide  at  the 
I  bottom  and  six  or  seven  feet  deep.    Around  the  bottom  make 
'  a  small  trench  draining  into  a  well  at  the  lower  end,  and  fill 
both  trench  and  well  with  stones.     Good  drainage  and  the 
absence  of  water  facilitates  oxidation  and  prevents  putre- 
faction. 

The  bodies  are  laid  across  in  three  or  four  superimposed 

'  rows,  the  rows  being  separated  by  brush  or  straw  or  the 

clothes  removed.    The  pit  is  then  filled  with  earth  which  is 

piled  above  the  ground  into  a  convex  or  ridged  top  capable 

i  of  shedding  the  rain.     The  greater  the  number  of  bodies 

'  buried  together,  the  more  rapid  will  be  the  disintegration  of 

the  bodies. 

In  selecting  sites  for  pits,  care  should  be  taken  that  they 
do  not  drain  into  nearby  watercourses  that  may  be  used  as  a 
source  of  water  supply. 
I      -Identification  tags  are  not  removed  from  the  dead  but  are 
.  left  on  the  bodies  when  interred.    Tags  found  on  the  bodies 
1  of  the  enemy's  dead  are  collected  and  turned  over  to  the 
1  commander  of  trains,  who  sends  them* to  the  provost  marshal 
I  at.  the  base.    (F.  S.  R.,  1914.)    When  burial  is  impossible  the 
,  putrefaction  of  large  numbers  of  dead  bodies  creates  an 
I  intolerable  nuisance,  and,   moreover,  the  burial  of  bodies 
does  not  prevent  the  development  of  the  fly  larvae  present 
on  them  or  the  subsequent  emergence  of  the  flies.     It  has 
been  found  that  if  such  bodies  are  treated  with  coal-tar 
creosote  oil,  putrefaction  and  the  resultant  odors  are  pre- 
vented;  flies  are  kifled  if.  already  present  and  others  are 
repelled.    For  general  purposes,  especially  when  the  repelling 
of  flies  is  of  importance,  the  following  mixture  is  recommended ; 


110  SANITATION  FOR  MEDICAL  OFFICERS 

coal-tar  creosote  oil  of  "country  make,"  containing  a  high 
percentage  of  phenolic  bodies,  to  which  sufficient  bases 
extracted  from  "light  oil"  are  added  to  make  the  proportion 
of  bases  to  phenolic  bodies  approximately  one  to  two. 

A  dead  body  or  carcass  that  cannot  be  disposed  of  imme- 
diately should  be  sprinkled  with  this  creosote-oil  mixture 
by  means  of  a  w^atering  can  and  the  fluid  distributed  in  the 
direction  of  the  hair  with  a  hard  brush.  When  the  whole 
of  one  side  has  been  treated  the  body  should  be  turned  over 
and  the  other  side  treated  in  the  same  way.  If  the  body  be 
large  the  abdominal  and  thoracic  cavities  may  be  opened 
and  some  of  the  fluid  poured  into  them.  It  may  be  desirable 
to  puncture  the  gut  to  allow  gases  to  escape  and  permit  the 
fluid  to  enter  the  intestines.  By  means  of  a  funnel  some  of  the 
fluid  may  be  poured  into  the  punctured  intestine.  Then 
small  quantities  should  be  poured  into  the  mouth,  eyes,  anus 
and  any  wounds  there  may  be.  About  a  gallon  suffices  for 
treating  a  horse,  half  a  gallon  for  the  external  treatment. 
Two  men  can  easily  treat  a  horse  in  fifteen  minutes,  and  this 
treatment  will  preserve  the  body  for  some  weeks  and  keep  off 
flies  for  some  days.  Fly  larvae  already  present  will  be  killed. 
Putrefying  bodies  should  be  sprayed  from  a  distance.  Almost 
immediately  the  stench  will  be  diminished  if  not  entirely 
obliterated.  Latrines,  manure  and  other  decomposing  organic 
material  may  be  treated  by  this  spray,  and  all  flies  touched 
by  the  spray  will  be  killed. 

Precautions. — The  liquid  is  an  irritant  and  the  hands  and 
face  should  be  washed  after  use,  as  it  burns  slightly  if  left  on. 
Protective  glasses  should  be  worn  by  the  men  using  the  spray. 
The  liquid  is  inflammable  and  care  should  be  used  that  there 
is  never  a  naked  flame  near  by  when  it  is  used  as  a  spray. 
The  flash-point  of  the  liquid  is  comparatively  high  and  the 
danger  of  fire  is  negligible  in  storehouses  or  in  ordinary 
methods  of  transit.  The  oil  should  never  be  used  in  a  w^atery 
emulsion,  as  such  emulsions  are  incapable  of  continued  action 


TRENCHES  AND  THE  BATTLEFIELD  111 

over  any  long  period  of  time.    The  desirable  properties  are 
possessed  only  by  undiluted  oily  reagents. 

Prisoners  of  War.  —  When  prisoners  are  taken  they 
should  be  moved  back  a  short  distance  to  a  detention  camp. 
The  sick  and  woimded  are  segregated  and  sent  to  hospital. 
They  are  detained  here  until  sick  are  isolated  and  those  who 
are  well  are  free  from  vermin,  and  are  then  moved  to  the 
prison  camp.  Upon  arrival  they  should  be  detained  in  isola- 
tion barracks  for  fourteen  days.  Hair  is  cut,  clothes  disin- 
fected. At  the  end  of  fourteen  days  they  should  be  mustered 
and  examined  again  for  vermin,  and  if  found  free  may  be  sent 
to  permanent  barracks  or  camp. 

The  prison  camp  should  have  its  own  hospital,  and  medical 
officers  attached,  who  should  see  that  the  same  sanitary 
orders  are  enforced  that  apply  in  any  camp.  Effort  must 
be  made  so  far  as  possible  to  provide  prisoners  with  all 
supplies  and  articles  essential  to  their  health,  and  they  should 
be  employed  in  some  useful  work.  There  is  a  natural  human 
tendency  to  feel  that  anything  is  good  enough  for  alien 
prisoners,  but  this  feeling  should  be  sternly  repressed.  We 
want  no  American  Wittenberg. 

The  disease  most  often  encountered  among  prisoners  has 
been  tuberculosis,  almost  always  due  to  poor  housing,  over- 
crowding, defective  food  and  other  insanitary  conditions. 
In  some  European  camps  the  morbidity  from  this  disease  has 
reached  2.5  to  3  per  cent.,  and  more  deaths  result  than  from 
all  other  causes  combined.  Next  in  order  of  occurences  are 
the  diarrheal  and  intestinal  diseases.  All  prisoners  should 
be  given  the  antityphoid  inoculation,  should  be  vaccinated 
against  smallpox,  and  should  be  mustered  and  inspected 
regularly  to  detect  infectious  diseases.  Particular  care 
should  be  taken  that  the  diet  is  sufficiently  ample  and  varied 
to  prevent  malnutrition  and  deficiency  diseases.  When 
possible  the  regular  army  ration  should^be  used. 

Prisoners  may  be  organized  into  companies  under  their  own 


112  SANITATION  FOR  MEDICAL  OFFICERS 

officers  for  administrative  and  sanitary  purposes,  and  these 
officers  may  be  made  responsible  for  the  maintenance  of  order, 
cleanHness  and  general  sanitary  requirements.  Camp 
inspections  must  be  thorough  and  cover  the  same  points 
covered  in  an  inspection  of  our  own  troops. 

SANITARY    ADMINISTRATION    OF    TERRITORY    UNDER    MILI- 
TARY CONTROL. 

The  sanitary  officers  of  an  invading  army  are  not  only 
morally  responsible  for  the  proper  sanitary  administration 
of  the  conquered  territory,  but  they  are  compelled  to  perform 
this  work  for  the  protection  of  their  own  army.  To  do  this 
successfully  requires  familiarity  with  military  methods 
together  with  a  general  knowledge  of  the  organization  of 
state  and  municipal  sanitary  departments.  Such  an  organi- 
zation should  include: 

I.  General  Administration. 

1 .  Clerical  Division. — Correspondence  and  current  business. 

2.  Property  Division. — Purchase,  storage  and  issue  of 
supplies. 

3.  Financial  Division. — Receipt  and  accounting  of  all 
money  and  disbursing  office  for  all  salaries. 

II.  Registration. 

1.  Vital  Statistics. — Births,  deaths,  issue  of  permits  for  burial. 

2.  Notification  of  communicable  diseases. 

III.  General  Sanitation. 

1.  Engineering. — Construction  of  buildings,  sewers,  drain- 
age, filtration  plants  and  other  public  works. 

2.  Inspection. — Nuisances,  disposal  of  refuse,  general 
sanitary  inspection. 

IV.  Prevention  and  Control  of  Communicable 
Diseases. 

I.  Epidemiology. — Investigation  of  the  source  of  all 
infectious  diseases,  'and  recommendation  of  measures  to 
prevent  spread. 


TRENCHES  AND  THE  BATTLEFIELD  113 

2.  Laboratory. — Both  diagnostic  and  research — investi- 
gation of  cause  of  epidemics. 

3.  Hospital  Division. — Transportation  and  treatment  of 
sick,  isolation  hospitals. 

The  headquarters  should  be  central  and  easy  of  access. 
The  chief  administrative  officer  should  be  an  experienced 
sanitarian  from  the  Army  Medical  Corps.  He  should  be 
directly  responsible  to  the  Commanding  General  and  subject 
to  no  other  authority.  Other  medical  officers  may  be  used  as 
chiefs  of  divisions  and  the  civilian  physicians  in  the  neighbor- 
hood should  be  employed  either  as  sanitary  inspectors  or  in 
the  hospitals.  The  chief  of  the  engineering  division  may  be 
an  engineer  officer  detached  for  this  duty,  but  should  be 
under  control  of  the  sanitary  officer.  A  suitable  number  of 
clerks  and  messengers  is  essential.  These  may  be  secured 
from  the  men  of  the  medical  department,  from  the  existing 
organization,  or  they  may  be  hired. 

Obtain  maps  as  soon  as  possible.  Divide  the  city  or 
territory  into  districts  of  suitable  size,  and  place  a  sanitary 
inspector  in  charge  of  each  district.  This  man  may  be  a 
medical  officer  or  a  civilian,  preferably  the  latter  if  men  of 
ability  and  responsiblity  can  be  obtained.  He  will  under- 
stand the  language  and  customs  of  the  inhabitants  better 
and  may  be  able  to  secure  better  results  for  this  reason.  There 
will  never  be  sufficient  medical  officers  for  the  entire  personnel, 
and  success  will  depend  upon  ability  to  use  civilian  physicians 
where  they  can  serve  best.  Each  district  inspector  should 
have  under  him  a  personnel  sufficient  for  the  work  to  be 
performed.  It  is  much  better  to  start  with  a  large  personnel 
and  reduce  it  as  sanitation  improves  than  to  start  with  a  small 
personnel  unable  to  cope  with  the  situation  and  necessitating 
constant  enlargement.  Laborers  for  sanitary  purposes  may 
be  secured  from  prisoners,  or  from  hired  civilians,  the  latter 
being  better  when  money  is  available,  and  such  sanitary 
squads  should  be  in  charge  of  a  non-commissioned  officer. 
8 


114  SANITATION  FOR  MEDICAL  OFFICERS 

i 

Money  for  such  sanitary  purposes  may  be  obtained  by 
taxation  or  from  military  funds. 

The  district  sanitary  officer  should  make  constant  and 
thorough  inspections,  using  a  regulation  form  that  can  be 
hied  in  district  headquarters  as  a  record.  Defects  found  may 
be  corrected  by  the  owner  of  the  premises  under  penalty  of 
a  fine,  by  the  sanitary  squad  under  the  direction  of  the 
inspector  or,  if  a  matter  of  poUce  only,  by  the  provost 
guard. 

In  performing  this  work,  active  or  passive  opposition  may 
be  expected  and  should  be  dealt  with  gently  but  firmly.  Do 
not  irritate  by  unnecessary  use  of  military  power  in  non- 
essentials, but  use  it  unhesitatingly  when  absolutely  neces- 
sary. It  should  be  remembered  that  more  can  be  accom- 
plished by  obtaining  the  good  will  of  the  population  than  by 
force.  It  should  be  made  plain  that  the  action  is  being  taken 
for  their  own  protection. 

As  soon  as  organization  is  completed,  a  precise  and  detailed 
sanitary  order  should  be  issued  to  all  inhabitants.  Whenever 
possible  this  should  be  based  on  previous  sanitary  laws  in 
order  to  avoid  unnecessary  innovations,  and  should  always 
be  in  the  language  of  the  country. 

The  home  life  of  all  non-combatants  must  be  respected. 
Refugees  should  be  returned  to  their  homes  if  possible,  first 
ascertaining  that  they  are  free  from  disease.  Provision  must 
be  made  for  those  having  no  homes,  and  public  buildings, 
schools,  churches,  warehouses  and  similar  buildings  may  be 
used,  or  temporary  quarters  may  be  built.  All  such  quarters 
must  be  carefully  inspected  to  ensure  compliance  with  sani- 
tary regulations.  It  may  be  necessary  to  issue  rations  to 
those  who  are  without  means  of  support.  Every  effort 
should  be  made  to  evacuate  such  camps  as  soon  as  possible. 

All  public  institutions,  including  jails,  asylums  and  hos- 
pitals should  be  inspected  at  once,  and  measures  taken  to 
place  them  in  a  sanitary  condition. 


TRENCHES  AND  THE  BATTLEFIELD  115 

Proper  water  supplies,  scavenger  service  and  other  services 
ordinarily  performed  by  health  departments  should  be 
undertaken  as  rapidly  as  funds  and  personnel  will  permit. 

The  epidemiologist  should  investigate,  with  the  assistance 
of  the  laboratory,  each  case  of  infectious  disease  that  is 
reported  and  the  proper  steps  taken  to  prevent  its  spread. 
Reporting  of  serious  infectious  diseases  may  be  controlled 
to  a  great  extent  by  refusal  to  issue  a  permit  for  burial  to 
cases  dying  under  suspicious  circumstances  until  a  post- 
mortem has  established  the  diagnosis.  Any  physician  issuing 
a  false  certificate  to  evade  the  military  regulations  may  be 
penalized. 


/I 


INSECTS  CONCERNED  IN  THE  TRANS- 
MISSION OF  DISEASE. 


ITCH  MITES. 


Although  these  are  not  insects  but  arachnids,  they  may 
be  conveniently  discussed  here. 

Classification. — Phylum  Arthropoda;  Class  Arachnida; 
Order  Acarina;  Family  Sarcoptidae. 

Sarcoptes  Scabiei. — The  parasite  that  causes  scabies  or 
itch.  The  body  is  oval  or  nearly  circular  and  whitish  in  color, 
covered  by  transverse  rows  of  folds  partly  interrupted  on  the 
back.  There  are  transverse  rows  of  small  bristles  on  the 
dorsal  surface  and  groups  of  trichomae  on  the  front,  sides  and 
back.  There  are  chitinous  hairs  at  the  base  of  the  legs.  The 
first  two  pairs  of  legs  are  provided  with  pedunculated  ambu- 
lacra in  both  sexes  and  the  two  posterior  pair  terminate  each 
with  a  long  bristle  in  the  female;  in  the  male  the  third  pair 
of  legs  terminate  in  a  bristle,  the  fourth  pair  with  a  pedun- 
culated ambulacrum.  The  anus  is  situated  at  the  posterior 
border  of  the  dorsal  surface. 

It  is  hardly  possible  to  distinguish  the  mite  of  human 
scabies  from  that  of  a  number  of  domestic  animals.  It  is 
best  therefore  to  name  but  one  species,  S.  scabiei,  which  may 
give  rise  to  different  races  or  varieties,  but  can  often  pass 
from  one  host  to  another.  The  varieties  found  in  the  sheep, 
goat,  camel,  dog  and  swine  have  been  known  to  pass  over  to 
man  and  occasionally  to  produce  a  severe  infection.  On  the 
other  hand,  rabbits  are  frequently  affected  by  scabies,  but  in 
a  long  experience  with  rabbits  a  transference  of  this  mite  to 
man  has  not  been  observed. 
(116) 


i 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     117" 

S.  Scahiei  of  Man  (Variety  Hominis). — Length  of  male, 
0.2  to  0.3  mm.;  breadth,  0.14  to  0.19  mm.  Length  of  female, 
0.33  to  0.45  mm.;  breadth,  0.25  to  0.35  mm.  It  lives  in  the 
tortuous  tunnels  which  it  excavates  in  the  skin,  and  the 
female  is  found  at  the  terminal  end,  while  excrement  and 
the  oval  eggs  deposited  by  the  female  may  also  be  found  in  the 
tunnel.    The  males  die  off  after  copulation  and  are  rarely 


Fig.  13. — Sarcoptes  scabiei:    Male  and  female. 
Furstenberg,  after  Murray.) 


(Reduced  from 


met  with.  The  females  die  after  depositing  their  eggs.  The 
six-legged  lar\^ae  hatch  out  after  four  to  eight  days,  and  after 
about  two  weeks,  during  which  time  they  moult  three  times 
and  undergo  their  metamorphosis  to  the  adult  four-legged 
and  sexually  mature  type,  they  begin  to  burrow  themselves. 
Transmission  from  person  to  person  is  generally  by  direct 
contact,  usually  when  sleeping  together,  or  by  coitus.     It 


118 


SANITATION  FOR  MEDICAL  OFFICERS 


must  not  be  forgotten  that  on  occasion  the  mite  may  also  be 
acquired  from  animals  having  scabies,  so  that  this  source  of 
infection  must  always  be  considered.     (See  note  on  Scabies.) 

FLEAS. 

Classification. — Suborder  Apheniptera  or  Siphonaptera. 
Family  Pulicidae.  While  there  are  about  200  species,  there  are 
only  three  genera  and  a  few  species  that  are  of  medical 
interest. 

1.  Genus  Pulex.     Pulex  irritans. 

2.  Genus  Xenopsylla  X.  cheopis. 

3.  Genus  Ctenocephalus  C.  canis. 


max.  p. 


hypoph. 
Fig.  14- "-Pulex  irritans. 


Pulex  Irritans. — The  human  flea.  This  species  can 
transmit  plague,  but  is  not  practically  concerned  in  the 
transmission  of  that  disease  because  in  nature  it  almost 
never  bites  rats.  It  may  be  identified  by  the  fact  that  it  has 
no  combs,  and  has  a  single  preocular  bristle. 

Xenopsylla  Cheopis. — This  is  the  rat  flea  of  the  tropics, 
but  also  bites  man  readily.  It  therefore  leaves  the  body  of 
the  rat  after  it  has  died  of  plague,  and  if  no  other  rat  is 
available  as  a  host  it  attacks  man.    This  flea  is  the  ordinary 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     119 

and  usual  plague  transmitter.  It  looks  somewhat  like  the 
human  flea  but  may  be  identified  by  the  fact  that  it  has  a 
V-shaped  row  of  bristles  on  the  posterior  and  lower  border 
of  the  head.  There  is  also  a  suture  on  the  mesopleura.  There 
are  no  combs,  and  there  is  a  preocular  bristle. 


anii. 


max. 
max.  p. 


Fig.   15. — Xenopsylla  cheopis. 

Ceratophyllus  Fasciatus. — Is  a  fairly  common  rat  flea,    ^ 
especially  in  Europe.     It  can  transmit  plague,  but  is  not    | 
usually  concerned.    It  has  a  row  of  combs  on  the  pronotum, 
but  none  on  the  head. 


ant.  groove 
max.  p. 


\-hypopIu 


max.  p. 
labialp. 
mand/ 
Fig.  16. — Ceratophyllus  fasciatus. 


Ctenocephalus  Canis. — The  ordinary  dog  and  cat  flea, 
but  may  also  be  found  on  rats  and  man.  It  is  of  no  practical 
importance  in  the  transmission  of  plague,  but  transmits  the 
tape-worm  Dipylidium  caninum.    It  is  easily  identified  by 


120 


SANITATION  FOR  MEDICAL  OFFICERS 


the  double  row  of  combs,  one  on  the  lower  border  of  the  head 
and  one  on  the  pronotum. 


anf. 


eye 


max.  p. 


Fig.  17- — Ctenocephalus  canis. 


Life  History. — Three  to  eighteen  eggs  are  laid.  These  are 
large  (0.5  mm.  long),  glistening,  white  and  blunt  at  both 
ends.  In  some  species  the  eggs  are  laid  in  the  cracks  of  the 
floor  or  in  loose  earth.  In  other  species  they  may  be  deposited 
on  the  dog  or  other  animal,  but  the  dry  eggs  fall  off  readily 
and  myriads  may  be  found  in  the  bed  of  a  flea-infested  animal. 
Development  always  takes  place  on  the  floor  or  ground.  The 
length  of  time  required  for  development  of  the  egg  depends 
upon  the  temperature,  and  may  last  from  two  to  fourteen 
days,  at  the  end  of  which  the  embrj-o  cuts  its  way  out  of  the 
egg  with  the  sharp  horn  on  its  head.  The  larva  is  worm-like, 
with  thirteen  segments,  and  is  very  slender  and  active,  with 
mouth  parts  of  the  biting  type.  It  lives  chiefly  upon  excre- 
mentitious  matter,  including  the  feces  of  the  adult  flea, 
which  often  contain  undigested  blood.  The  lars^al  stage 
requires  seven  to  thirty  days,  depending  upon  circumstances. 
At  the  end  of  the  larval  period  the  insect  spins  a  whitish  silken 
cocoon  in  which  the  pupa  rests,  and  the  fully  developed  flea 
emerges  in  from  ten  to  fourteen  days.     Under  ordinary  cir- 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     121 

cumstances  it  may  be  estimated  that  it  takes  about  a  month 
from  the  egg  to  the  adult  flea. 

Longevity  of  Fleas. — Laboratory  experiments  indicate 
that  when  deprived  of  an  opportunity  of  feeding,  fleas  die 
in  six  days  or  less.  Rat  fleas  fed  on  human  blood  averaged 
eight  and  a  half  days  (maximum  seventeen)  for  the  males 
and  thirty-two  days  (maximum  i6o)  for  the  females. 

Repellants. — Essential  oils  have  a  stupefying  effect  on 
fleas  when  used  in  strong  concentration.  It  is  probable  that 
rubbing  the  body  with  oil  of  citronella  would  repel  fleas. 

Destruction  of  Fleas. — If  the  larvae  are  killed,  fleas  wiU 
soon  disappear.  Kerosene  and  miscible  oil  are  extremely 
efiicient  puUcides.  Floors  and  the  ground  under  houses  may 
be  thoroughly  sprinkled  with  kerosene,  and  the  posts  support- 
ing the  houses  may  be  smeared  with  crude  ofl.  Very  few  other 
substances  wfll  serve;  water,  glycerin  and  alcohol  are 
inefficient,  and  formaUn,  phenol,  mercuric  chloride  and 
tricresol  in  the  strengths  used  as  disinfectants  are  of  little 
value  in  killing  fleas.  Powdered  sulphur  has  also  been  found 
to  be  of  no  value.  The  fumigants  bisulphide  of  carbon, 
hydrocyanic  gas,  and  sulphur  dioxide  are  highly  efficient, 
but  the  first  two  are  dangerous,  and  should  only  be  used  by 
those  instructed  in  their  use.  When  dog  and  cat  fleas  are 
about  they  are  sometimes  mistaken  for  human  fleas,  and  the 
measures  outlined  above  may  fail  to  destroy  them  because 
the  beds  of  the  dogs  or  cats  are  overlooked. 

To  Collect  Fleas  from  Plague  Houses. — Leave  several  guinea- 
pigs  in  the  house  for  a  day  or  two.  Then  anesthetize  to 
stupefy  the  fleas  and  comb  the  fleas  from  the  hair,  dropping 
them  in  kerosene.  The  species  of  fleas  found  in  plague  houses 
may  be  determined  in  this  way. 

FLIES. 

Flies  are  not  only  a  great  nuisance  in  camp  but  they  spread 
many  diseases,  including  typhoid  and  the  dysenteries,  and 


122 


SANITATION  FOR  MEDICAL  OFFICERS 


for  this  reason  the  greatest  care  mus.t  be  taken  to  prevent 
fly  breeding  and  the  access  of  flies  to  food  or  excreta.  The  fly 
that  causes  the  most  trouble  is  the  common  house  fly  (Musca 
domestica).  This  fly  cannot  bite.  The  stable  fly  (Stomoxys 
calcitrans)  looks  much  like  the  house  fly  and  is  a  savage 
biter.  Because  of  this  fact  the  stable  fly  is  not  as  dangerous 
as  the  house  fly  as  a  disease  transmitter,  but  it  is  an  even 
greater  nuisance.  In  order  to  combat  flies,  some  knowledge 
of  their  life  cycle,  and  particularly  of  their  breeding  habits, 


Fig.  i8. — Common  house  fly  (Musca  domestica):  Puparium  at  left; 
adult  next;  larva  and  enlarged  parts  at  right.  All  enlarged.  (After 
Howard,  Div.  Ent.,  U.  S.  Dept.  Ag.) 

'  is  absolutely  necessary.  The  breeding  habits  of  the  house 
fly  and  the  stable  fly  are  practically  identical,  so  that  for 
sanitary  purposes  they  may  be  considered  together. 

Life  Cycle. — The  adult  house  fly  lives  chiefly  in  human 
habitations,  and  98  per  cent,  of  the  flies  found  in  dining  rooms 
and  kitchens  are  Musca  domestica.  Female  flies  begin 
depositing  eggs  from  nine  to  twelve  days  after  emerging  from 
the  pupa  case.  From  seventy-five  to  one  hundred  and  fifty 
eggs  are  deposited  singly,  piling  up  in  masses,  and  there  are 
usually  two  to  four  such  layings  at  intervals  of  three  or  four 
days.     Dunn  has  found  in  the  Canal  Zone  that  one  female 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     123 

may  deposit  as  many  as  2387  eggs,  or  as  high  as  twenty-one 
batches  of  eggs,  within  thirty-one  days  after  emxergence. 
Horse  manure  is  the  favorite  material  upon  which  eggs  are 
deposited  and  upon  which  the  lars^ae  feed,  but  they  com- 
monly develop  also  in  human  feces,  kitchen  refuse  and  other 
decaying  organic  matter.  Probably  when  horse  manure  is 
not  carefully  removed,  95  per  cent,  of  the  flies  originate  from 
this  source.  Therefore  in  any  campaign  against  flies  th-e 
disposition  of  horse  manure  must  receive  the  most  attention. 
It  must  not  be  forgotten,  however,  that  flies  breed  in  any 
decaying  organic  matter,  and  will  often  lay  their  eggs  upon 
the  ground  around  garbage  cans  and  incinerators  which  has 
become  soiled  by  throwing  slops  at  the  can  or  incinerator 
instead  of  pouring  them  into  these  receptacles. 

The  eggs  of  the  house  fly  hatch  in  fiom  twelve  to  twenty- 
four  hours,  and  the  larvae  begin  feeding  at  once  and  grow 
rapidly.  The  larval  stage  is  the  growing  period  of  the  fly, 
and  the  size  of  the  adult  will  depend  upon  the  size  the  larva 
attains.  The  larval  stage  lasts  from  four  to  six  days,  after 
which  the  maggots  leave  the  manure  pile  and  burrow  into  the 
ground  beneath  it,  where  they  pupate  or  go  into  a  resting 
stage,  during  which  the  transformation  to  the  adult  fly 
occurs.  The  time  required  from  the  laying  of  the  egg  to  the 
emergence  of  the  adult  fly  is  from  ten  to  fourteen  days  in 
warm  weather.  Cold  weather  lengthens  the  period  of 
development. 

It  is  important  to  note  this  habit  of  the  maggots  of  burrow- 
ing into  the  earth  to  pupate.  The  ground  around  picket  Hnes, 
or  where  kitchen  wastes  are  thrown,  may  contain  milHons  of 
these  larvae  or  pupae,  even  though  the  manure  and  wastes  are 
removed.  Throwing  fresh  earth  upon  these  places  not  only 
does  no  good,  but  favors  the  development  of  the  fhes,  which 
can  emerge  through  six  feet  of  earth.  Burning  the  ground 
over  wall  not  destroy  larvae  that  have  already  penetrated  the 
ground,  for  the  heat  does  not  penetrate  the  ground  more  than 


124  SANITATION  FOR  MEDICAL  OFFICERS 

an  inch  or  so.  The  only  method  of  preventing  this  source  of 
breeding  is  to  remove  all  manure  promptly  (daily) ,  and  even 
then  flies  will  lay  their  eggs  on  the  soil  around  the  remnants 
that  escape  and  the  larvae  will  gain  access  to  the  soil.  (See 
care  of  Picket  Lines.) 

Range  of  Flight. — Ordinarily  flies  remain  near  the  place 
where  they  originated,  and  when  flies  are  numerous,  search 
should  be  made  near  by  for  breeding  places.  However,  when 
food  is  not  abundant  near  by,  flies  may  travel  several  miles, 
as  has  been  proved  by  observation  and  experiment. 

Longevity  of  Flies. — Under  ordinary  conditions  flies 
live  from  thirty  to  sixty  days  during  the  summer  months. 
They  may  hibernate  and  live  over  the  winter. 

Feeding  Habits  and  Disease  Transmission. — The  mouth 
parts  of  the  house  fly  are  fused  into  a  proboscis,  so  that  it 
cannot  bite  and  cannot  eat  solid  matter.  It  obtains  solid 
matter,  such  as  sugar,  by  regurgitating  droplets  from  its 
stomach  upon  the  food,  and  then  sucking  them  back  after 
these  droplets  have  dissolved  some  of  the  food.  As  many 
disease  organisms  may  remain  in  a  virulent  condition  in  the 
intestinal  tract  of  flies,  these  may  be  readily  deposited  upon 
the  food  in  this  way.  It  has  been  shown  experimentally  that 
living  typhoid  bacilh  may  remain  in  and  upon  the  bodies  of 
flies  for  as  long  as  twenty-three  days  after  infection,  and  they 
excrete  tubercle  bacilli  for  at  least  six  days  after  feeding  on 
tuberculous  sputum ;  the  eggs  of  various  parasitic  worms  may 
also  be  carried  by  flies.  In  addition  to  regurgitation  the  fly 
defecates  frequently  while  feeding,  and  disease  organisms  are" 
also  deposited  on  the  food  in  this  way.  The  fly  is  particularly 
fond  of  the  food  prepared  in  the  kitchen  and  also  of  human 
feces.  It  frequently  travels  from  the  latter  to  the  former  and 
wipes  its  feet  on  the  food.  Should  disease  organisms  be 
present  in  the  stools  of  carriers  or  actual  cases  of  the  disease 
they  may  therefore  be  carried  directly  to  the  food  by  flies, 
on  their  feet,  by  defecation  and  by  regurgitation  on  the  food. 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     125 

Elimination  of  Flies  from  Camp. — I.  Measures  directed 
against  fly  breeding.  These  subjects  are  dealt  with  in  special 
notes. 

1.  Prompt  disposal  of  manure. 

2.  Incineration  of  atl  garbage  and  kitchen  wastes. 

3.  Sanitary  disposal  of  human  feces  in  fly- tight  latrines. 

II.  Measures  to  kill  adults  already  present. 

1.  Fly  traps. 

2.  Fly  papers  and  poisons. 

III.  Measures  to  prevent  access  of  flies  to  food. 
I.  Screening  of  kitchens  and  mess  halls. 

Fly  Traps. — Are  constructed  on  the  principle  that  flies 
are  attracted  through  the  dark  opening  at  the  bottom  of  the 
trap  by  the  sense  of  smell.  After  feeding,  they  attempt  to 
leave  by  flying  toward  the  Hght,  and  so  enter  the  trap. 
Traps  must  therefore  be  raised  a  sufiicient  distance  from  the 
ground  to  allow  free  access  to  flies,  and  must  always  be  baited 
with  some  attractive  odorous  substance.  Flies  will  not 
enter  a  trap  that  is  not  baited  properly,  but  in  spite  of  this 
fact,  in  many  camps  traps  have  been  left  without  bait.  An 
old  decaying  flsh  head  or  the  following  solutions  may  be 
used:  Molasses  one  part  to  water  three  parts;  brown  sugar 
one  part  to  water  four  parts.  Both  of  these  solutions  are 
more  attractive  after  they  have  fermented.  Vinegar  and 
sugar  may  be  used  or  sour  milk.  Whenever  fhes  are  numer- 
ous, fly  traps  should  be  used  both  inside  and  outside  the  mess 
halls  and  kitchens  in  the  number  prescribed  by  the  sanitary 
officer,  and  daily  inspection  of  these  traps  should  be  made, 
to  ensure  that  they  are  baited  properly  and  working  efficiently 
(see  Fig.  19). 

Sticky  Fly  Papers. — Are  fairly  efficient  and  may  be  pur- 
chased from  the  mess  funds  and  used  if  desired. 

Fly  Poisons. — Are  very  efficient  and  safe  when  properly 
prepared.  A  good  fly  poison  should  be  attractive  to  flies, 
for  it  may  be  assumed  that  there  are  alternative  drinking 


126  SANITATION  FOR  MEDICAL  OFFICERS 

places.  Formaldehyde  in  a  concentration  of  0.5  to  i  per 
cent,  is  attractive  to  flies,  and  is  more  efficient  than  any 
other  fly  poison.  Sodium  salicylate  in  i  per  cent,  solution 
is  almost  as  efficient,  and  is  easier  to  keep  and  handle.  A 
formaldehyde  solution  of  i  per  cent,  corresponds  to  2.5  per 
cent,  of  the  40  per  cent,  solution  sold  as  formalin.    If  accurate 


Fig.  19. — Fly  trap,  as  made  by  company  artificer.     (Keefer,  Military 

Hvmene.^ 


Hygiene.) 

solutions  cannot  be  obtained,  use  3  teaspoonfuls  of  40  per 
cent,  formaldehyde  to  a  pint  of  water,  or  3  teaspoonfuls  of 
powdered  sodium  salicylate  to  a  pint. 

Directions  for  Use. — Nearly  fill  a  glass  tumbler  with  the 
solution,  place  over  this  a  piece  of  blotting  paper,  cut  cir- 
cular and  somewhat  larger  than  the  tumbler,  and  over  this 
place  a  saucer.     Invert  the  whole  device  and  insert  a  match 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     127 

or  toothpick  under  the  edge  of  the  tumbler  to  permit  access 
of  air.  The  blotting  paper  will  remain  in  the  proper  moist 
condition  until  the  entire  contents  of  the  tumbler  have  been 
used.  A  very  little  sugar  sprinkled  on  the  paper  may  increase 
the  attractiveness  of  the  poison  for  the  flies,  but  care  should 
be  used  not  to  use  too  much.  These  poisons  kill  flies  in  a 
few  minutes  after  drinking.  FUes  drink  best  in  the  early 
morning,  and  the  poison  should  be  set  at  night  so  that  it 
will  be  ready. 

Fly  Swatting. — Should  flies  gain  access  to  the  kitchens  or 
mess  halls  they  may  be  killed  by  swatting.  It  should  be 
understood,  however,  that  this  is  the  poorest  method  of 
killing  flies  and  indicates  that  the  other  methods  outlined 
are  not  being  carried  out  efficiently.  If  fly  breeding  is  con- 
troUed,  fly  screening  is  effective,  and  poisons  and  traps  used 
to  kill  the  few  flies  that  enter  the  kitchen  and  mess  hall, 
there  should  be  little  opportunity  for  fly  swatting,  a  method 
that  is  time-consuming  and  inefficient. 

LICE. 

Pediculosis   and   the   diseases   transmitted  by  lice  have 
constituted  one  of  the  greatest  sanitary  problems  during  the 
present  war.    It  has  been  definitely  proved  that  lice  transmit 
typhus  fever,  relapsing  fever  and  trench  fever,  and  there  is 
some  evidence  that  they  may  transmit  other  diseases.    The 
louse  has  been  responsible  for  more  diseases  during  the  present 
war  than  any  other  single  factor.     Typhus  fever  has  fre- 
quently occurred,  and  in  Serbia  alone  the  deaths  from  typhus 
were  reckoned  at  500  a  day  in  February,  191 5.    Trench  fever 
has  caused  a  greater  amount  of  morbidity  than  any  other 
I  one  disease  on  the  Western  front,  with  more  than  30,000 
'  cases  up  to  June,  191 7.    Aside  from  the  transmission  of  these 
I  diseases,  lice  cause  much  discomfort,  sleeplessness  and  con- 
'  sequent  loss  of  efficiency,  and  constitute  a  severe  trial  to 
,  soldiers. 

i 


128  SANITATION  FOR  MEDICAL  OFFICERS 

Classification. — Order  Hemiptera.  Suborder  Aptera. 
Family  Pediculidae. 

Genus  i.  Pediculus. — Thorax  and  abdomen  separate. 

Genus  2.  Phthirus. — Large  thorax  not  separated  from  the 
abdomen.    Species  P.  inguinaUs  (the  crab  louse). 

Genus  i.  Pediculus. — It  was  formerly  considered  that  there 
were  two  species,  P.  capitis  and  P.  corporis  (vestimenti). 
Since  it  has  been  shown  that  it  is  possible  to  cross  P.  capitis 
and  P.  corporis  resulting  in  fertile  offspring,  there  has  been 
a  tendency  to  consider  them  as  varieties  of  a  single  species, 
P.  humanus. 


V 


Fig.  20. — Pediculus  capitis:  male.    (After  Kiichenmeister.) 

P.  CAPITIS  {The  Head  Louse). — Of  gray  color;  abdomen 
composed  of  seven  segments.  Male,  1.6  mm.  long  by  0.7  mm. 
wide.  Female,  2.7  mm.  long  and  i  mm.  wide.  They  live  in 
the  hair  of  the  head,  occasionally  in  the  eyebrows  and  beard. 
The  female  attaches  the  eggs  or  nits  to  the  hair  at  the  base. 

Anderson  and  Goldberger  showed  that  it  can  transmit 
typhus,  and  Foster  described  an  epidemic  in  Mindanao  due 
to  capitis,  but  it  is  probably  not  the  usual  transmitter. 

P.  CORPORIS  (vestimenti).  (The  Clothes  Louse.) — Is  larger 
than  P.  capitis,  the  male  being  3  mm.  long  by  i  mm.  wide, 
and  the  female  3  mm.  long  by  i.i  mm.  wide.    The  head  is  less 


I 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     129 

rounded  than  that  of  capitis,  and  has  longer  antennae.  (See 
Fig.  21.)  The  abdomen  is  broader  than  the  thorax  and  is 
composed  of  eight  segments.  This  louse  lives  chiefly  in  the 
clothes  even  when  it  bites,  though  they  may  be  foxmd  upon 
the  hairs  of  the  body.  The  inner  clothing  is  preferred,  but 
it  also  lives  in  the  outer  clothing.  They  are  most  frequently 
foimd  in  the  seams  of  the  undershirt,  drawers  and  fork  of 
the  trousers,  and  in  the  arm  pits.  Eggs  are  usually  laid  in 
the  seams  of  the  clothing,  but  may  be  laid  upon  the  body 


Fig.  21. — Pediculus  corporis:  female.    (After  Kiichenmeister.) 

t 

hair.  To  find  these  lice  a  thorough  search  should  be  made 
I  in  the  seams  of  the  inner  and  outer  clothing,  and  the  hair  of 
;  the  axillae,  chest  and  pubic  regions  should  also  be  examined. 
1  This  louse  is  the  cormnon  transmitter  of  typhus  fever,  relaps- 
j  ing  fever  and  trench  fever. 

!  Phthirus  iNGxnNALis.  The  Crab  Louse  (see  Fig.  22). — The 
I  head  is  relatively  short  and  engaged  in  a  depression  in  the  tho- 
I  rax,  which  is  larger  than  the  abdomen.  The  abdomen  is  formed 

of  six  rings,  but  the  second,  carrying  three  stigmata,  is  formed 
9  , 


130 


SANITATION  FOR  MEDICAL  OFFICERS 


from  the  fusion  of  the  second,  third  and  fourth  segments. 
The  feet  are  armed  with  powerful  claws.  The  males  are  about 
I  mm.  long  and  the  females  about  1.5  mm.  long.  They  live 
habitually  in  the  hair  of  the  pubis  and  perineum,  but  may 
larely  attack  the  hair  of  the  beard,  moustache,  eyebrows, 
etc.  The  eggs  are  fixed  at  the  base  of  the  hairs,  and  the 
young  are  born  on  the  seventeenth  day  and  may  reproduce 
fifteen  days  after  birth.  It  is  easily  distinguished  from  the 
other  two  species  of  lice,  because  there  is  no  separation  of 


Fig.  22. — Pediculus  pubis.     (After  Schmarda.) 


thorax  and  abdomen.  It  is  naturally  suggested  that  it  may 
have  something  to  do  with  typhus  fever,  but  no  experimental 
work  has  been  done.  It  is  not  likely  that  it  is  important  as 
a  transmitter,  because  its  habits  are  not  in  keeping  with 
the  known  epidemiology  of  typhus.  Like  other  lice  the  eggs 
are  very  difficult  to  destroy. 

Bionomics  of  Lice. — Life  Cycle. — Under  favorable  cir- 
cumstances, oviposition  commences  from  twenty-four  to 
thirty-six  hours  after  the  emergence  of  the  female  from  the 


INSECTS  CONOERNED  IN  TRANSMISSION  OF  DISEASE     131 

third  larval  moult.  The  eggs  are  laid  daily  and  the  number 
of  eggs  laid  depends  upon  the  temperature  and  food  supply. 
P.  corporis  may  lay  from  70  to  300  eggs,  and  P.  capitis  has 
been  observed  to  lay  141  eggs.  Nuttall  thinks  that  under  * 
natural  conditions  275  to  300  eggs  is  a  normal  number. 
From  9  to  12  eggs  are  laid  daily.  P.  corporis  ceases  to  lay 
at  temperatures  below  20°  C,  so  that  the  simple  removal 
of  clothing  at  night  tends  to  reduce  infestation.  The  egg  is 
attached  to  the  clothing  or  hair  by  cement.  P.  corporis 
shows  a  marked  preference  for  laying  on  fabrics  even 
though  hair  be  present,  while  capitis  shows  a  marked 
preference  for  hair.  Fur,  felt  and  wool  are  preferred  for 
oviposition,  but  eggs  are  also  laid  on  silk.  Silk  under- 
clothing will  not  prevent  infestation.  Under  proper  con- 
ditions of  temperature  and  moisture  it  takes  from  four 
to  eight  days  for  the  eggs  to  mature.  Eggs  may  remain 
dormant  away  from  the  body  for  forty  days.  Eggs  on  cloth- 
ing may  therefore  serve  as  a  source  of  infestation  for  a  month 
at  least.  Recently  hatched  lice  feed  immediately,  and  if  no 
food  is  obtained  they  usually  die  in  twenty-four  hours.  The 
young  resemble  the  adult  except  that  they  are  smaller.  They 
require  from  ten  to  fourteen  days  to  attain  sexual  maturity, 
and  while  developing  they  pass  through  three  successive 
moults.  The  female  is  then  fertilized  and  commences  to  lay 
eggs.  The  length  of  life  of  lice  varies,  but  ranges  from  thirty 
to  forty-five  days  under  favorable  circumstances.  The 
females  live  the  longest,  and  P.  corporis  lives  some  days 
longer  than  P.  capitis. 

Feeding  Habits. — Normally  adult  lice  feed  about  twice  a 
day  for  twenty  minutes.  They  often  feed  greedily,  so  that 
the  body  swells  with  the  ingested  blood,  and  the  gut  may 
even  rupture,  thus  causing  the  death  of  the  louse.  As  the 
intestine  fills,  excreta  are  commonly  voided.  Lice  feed  most 
commonly  at  night,  but  will  bite  at  other  times  when  the  body 
is  quiet.     As  the  result  of  many  experiments  it  has  been 


132  SANITATION  FOR  MEDICAL  OFFICERS 

found  that  the  longest  period  during  which  Hce  sundved 
separation  from  the  body  was  about  nine  to  ten  days. 

Susceptibility  to  Extremes  of  Temperature. — Lice  are 
attracted  by  warmth  and  will  crawl  from  cold  surfaces  to 
warm  ones,  but  they  cannot  stand  extremes  of  heat.  They^ 
are  killed  in  a  few  minutes  at  45°  to  50°  C.  Body  lice  are 
seldom  found  in  the  tropics  and  thrive  best  during  the  cooL 
seasons.  It  is  said  that  a  man  from  Mexico  City,  where  it  is 
cool,  may  come  down  to  Vera  Cruz  lousy,  but  loses  them  all  in 
a  few  days  because  of  the  increased  heat.  Lice  may  survive 
freezing  temperature  for  several  days,  and  the  eggs  survive 
freezing  for  eight  days.  Lice  may  also  survdve  immersion 
in  water  for  from  fourteen  to  twenty-eight  hours  and  eggs 
for  ninety-six  hours.  Washing  clothes  in  cold  water  is  there- 
fore quite  ineffective  in  destroying  lice. 

Locomotory  Powers. — Lice  may  travel  considerable  dis- 
tances when  separated  from  the  body.  They  have  been 
observ^ed  to  travel  five  feet  horizontally  and  three  feet  up 
the  wall  of  a  room.  Over  horizontal  surfaces  they  may  move 
from  6  to  22  cm.  a  minute,  depending  on  the  character  and 
temperature  of  the  surface.  Murchison,  in  1884,  cautioned 
against  sitting  on  the  beds  of  typhus  patients,  and  there  is 
one  case  mentioned  where  a  judge  contracted  typhus  from  a 
prisoner  under  trial.  This  was  formerly  regarded  as  proof 
that  the  disease  was  air-borne. 

Prevalence  of  Lice. — The  percentage  of  the  population 
infested  varies  according  to  circumstances.  In  former  days 
it  was  not  considered  disgraceful,  and  even  royalty  was  not 
exempt.  Today  pediculosis  is  practically  confined  to  the 
poorer  populations,  but  when  large  bodies  of  troops  are 
assembled  there  are  always  a  few  lousy  men,  and  these  suffice 
to  cause  a  general  infestation  unless  adequate  precautions 
are  taken.  Among  patients  admitted  to  hospital  in  Boston 
5.5  per  cent,  were  verminous.  Observations  recently  made 
in  this  country  showed  that  42  per  cent,  of  a  certain  group 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     133 

of  negro  soldiers  were  infested,  and  59  per  cent,  of  the  pros- 
titutes examined.  The  crab  louse  is  disseminated  chiefly  by 
sexual  intercourse.  In  an  investigation  conducted  at  the 
port  of  embarkation  pediculosis  was  found  to  average  one 
case  per  500  men.  As  the  result  of  precautions  taken  at  the 
port  no  case  of  pediculosis  was  found  among  soldiers  on  the 
transports.  No  cases  were  found  among  men  who  had  just 
arrived  in  England,  but  among  184  men  who  had  been  two 
months  in  a  rest  camp  in  England  there  were  36  cases  of 
pediculosis.  Peacock  examined  the  men  of  one  division  in 
France  and  found  95  per  cent,  of  the  men  infested  with  an 
average  of  twenty  lice  per  man.  Five  per  cent,  were  maximum 
cases,  the  number  of  lice  ranging  from  200  to  10,000  per  man. 

Methods  of  Dissemination. — The  main  source  of  infesta- 
tion is  the  heavily  infested  man  who  serves  as  a  carrier.  Con- 
tact with  the  clothing  and  bedding  previously  used  by  infested 
persons  is  an  important  source.  Infestation  through  stray 
lice  may  occur  infrequently.  The  main  influence  in  permit- 
ting infestation  is  the  continuous  wearing  of  clothing.  The 
frequent  change  and  proper  laundering  of  apparel  reduces 
the  danger  of  infestation  to  small  proportions,  and  the  lack 
of  facilities  for  this  purpose  has  produced  the  louse  problem 
among  troops. 

Delousing.  p.  capitis. — The  hair  should  be  worn  short. 
When  infestation  has  occurred  the  hair  should  be  clipped 
with  a  hair  clipper,  caught  in  bags  and  burned.  The  head 
may  then  be  washed  with  a  mixture  of  equal  parts  of  kerosene 
and  vinegar,  followed  in  a  few  hours  by  a  bath  with  soap  and 
warm  water.  Following  this  treatment,  search  should  be 
made  for  nits  and  lice,  and  if  found  the  treatment  should 
be  repeated.  Carbolic  acid  is  also  effective  in  solution  or 
as  a  pomade.  Soak  the  hair  in  a  2  per  cent,  solution  and 
apply  a  turban.  Remove  after  one  hour  and  wash  head  or 
merely  allow  the  carbolic  to  dry.  The  pomade  can  be  used  on 
children. 


134  SANITATION  FOR  MEDICAL  OFFICERS 

P.  Inguinalis.  Crab  Louse. — Shave  the  hair  of  the  pubic 
region,  legs  or  other  affected  areas.  Apply  the  mixture  of 
kerosene  and  vinegar  and  follow  with  a  bath  of  soap  and  hot 
water.  Mercurial  ointment  is  frequently  used  but  may 
cause  dermatitis.  The  following  substitutes  are  recommended: 
Yellow  oxide  of  mercury  lo  parts,  salicylic  acid  i  part, 
vaseline  90  parts,  powdered  ammoniated  mercury  5  grams, 
benzoated  lard  95  grams.  ^     . 

P.  corporis  {vestimenti) .  The  Clothes  Louse. — Infestation' 
may  be  prevented  by  the  following  measures: 

1.  The  soldier  should  be  inspected  once  a  week.  This 
inspection  can  be  combined  with  other  physical  inspections. 
Scabies  should  also  be  searched  for.  Pediculosis  does  not 
affect  the  fingers,  wTists  and  forearms. 

2.  Men  who  are  verminous  should  be  disinfected  as  soon 
as  possible. 

3.  All  soldiers  should  receive  a  bath  once  a  week  or  at 
least  once  in  two  weeks,  followed  by  a  change  of  underwear. 

4.  When  men  are  prone  to  become  verminous,  disinfesta- 
tion  should  be  practised  every  two  weeks,  and  should  be 
applied  to  all  of  the  men  who  live  in  close  association,  together 
with  the  clothing  and  bedding. 

5.  Soldiers  proceeding  to  the  front  or  returning  thence 
should  be  examined  before  being  allowed  to  mix  with  other 
men.  ■ 

6.  The  personnel  employed  in  delousing  should  be  per- 
manent, specially  instructed  and  should  wear  protective 
clothing. 

The  only  thoroughly  reliable  means  of  destroying  lice  are 
hot  air  and  steam.  Sulphur  dioxide  is  unreliable  and  insecti- 
cides are  merely  palliative  and  protective,  since  they  fail 
to  destroy  the  nits.  Both  lice  and  nits  are  killed  by  a  moder- 
ate degree  of  dry  heat,  55°  C.  in  five  minutes  or  65°  to  70°  in 
one  minute;  but  in  practice  the  exposure  should  be  lengthened 
to  permit  penetration.    When  immersed  in  water  at  70°  C. 


j  INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     135 

j  lice  are  killed  in  five  seconds,  but  in  practice  articles  should 
'  be  immersed  ten  minutes.    Lice  are  killed  instantly  at  80° 
,  C.  and  in  a  steam  disinfector  that  has  been  properly  packed 
I  the  exposure  need  not  exceed  fifteen  minutes.    Exposure  to 
I  60°  C.  for  fifteen  minutes  kills  both  lice  and  nits,  and  if 
I  garments  are  steeped  in  a  2  per  cent,  solution  of  lysol  at  a 
temperature  of  50°  F.  both  lice  and  nits  are  killed. 
I     Steam  Laundry. — In  the  usual  laundering  process  cotton 
goods  are  subjected  to  a  temperature  of  180°  F.  or  82°  C 
for  at  least  fifteen  minutes,  so  that  it  is  probable  that  all  lice 
and  eggs  would  be  killed  in  such  a  process.     For  woolen 
clothes  only  115°  F.  or  46°  C.  is  used,  a  temperature  insuffi- 
cient to  kill.    If  this  process  were  combined  with  a  cresol  soap 
both  lice  and  eggs  could  probably  be  killed.    The  installation 
of  proper  steam  laundry  facilities  in  France  would  go  far 
toward  eradicating  the  louse. 

Insecticides. — These  are  sometimes  efficient  against  adult 
lice,  but  do  not  kill  the  eggs.  Naphthaline  has  proved  very 
efficient  and  is  easy  to  obtain,  Moore  has  found  that  helio- 
tropine  or  piperonal  is  most  effective,  killing  100  per  cent, 
of  lice  within  twelve  hours  and  remaining  effective  after  a 
period  of  528  hours.  Heliotropine  is  most  soluble  in  cocoa 
butter.  If  underwear  was  impregnated  with  i  gram  helio- 
tropine and  3  grams  of  cocoa  butter  dissolved  in  ether  to 
each  48  square  inches  the  underwear  could  be  worn  for 
168  hours  without  losing  its  toxicity.  This  does  not  appear 
practical  on  a  large  scale.  Naphthaline  is  quite  practical. 
Naphthaline  must  be  renewed  at  intervals  of  about  three 
days  to  be  effective.  For  further  information  concerning 
prophylactic  methods  and  the  process  of  delousing  troops,  see 
note  on  Typhus  Fever. 

Effects  of  Disinfestation  on  Clothing. — Leather,  furs, 
rubber  and  articles  containing  glue,  wax  or  varnish  are  unsuit- 
able for  treatment  by  steam.  Woolen  clothing  is  liable  to  shrink 
and  some  colors  run.     Articles  containing  wax  and  rubber 


136 


SANITATION  FOR  MEDICAL  OFFICERS 


are  not  suitable  for  hot  air  treatment.  Hot  air  at  104°  C. 
causes  yellowing  of  flannel  and  exposure  to  127°  C.  for  half 
an  hour  destroys  its  tensile  strength  and  it  becomes  brittle. 
Wet  leather  wiU  shrink  and  grow  hard  if  exposed  to  dry  heat. 
It  should  be  dried  before  exposure.  Furs  are  not  damaged 
by  80°  C.  for  thirty  minutes,  but  they  are  damaged  by  78° 
C.  for  two  hours. 

In  treating  clotning  for  destruction  of  lice  an  exposure  of 
60°  C.  for  half  an  hour  is  sufficient. 


Fig.  23.^-Body  of  C.  when  rest- 
ing is  held  parallel  to  wall  in  a 
curved  position.      (Park.) 


Fig.  24.— Body  of  A.  stands  at 
an  angle  of  about  45  degrees  and 
is  straight.      (Park.) 


MOSQUITOES. 

In  this  discussion  of  mosquitoes  no  attempt  is  made  to 
describe  details  of  structure  or  classification,  but  to  present 
the  minimum  of  classification  w^hich  should  be  accessible  to 
every  medical  officer  in  order  that  he  may  perform  his  sani- 
tary duties  efficiently.  For  further  information  see  Bulle- 
tin No.  4,  W.  D.,  Office  of  the  Surgeon-General. 

Classification. — Family  Cuhcida),  subfamilies  Anophe- 
linse  and  Culicinae.    The  males  do  not  bite,  but  the  females 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     137 

must  have  a  meal  of  blood  before  they  can  lay  their  eggs. 
Since  the  males  do  not  feed  on  blood  they  are  less  frequently 
found  about  habitations,  and  the  female  is  generally  used  for 
classification.    The  males  of  most  species  have  plumose  or 


Fig.  25. — Egg  of  Anopheles  maculipenni".     On  the  left  the  egg  is  seen 
from  above,  and  on  the  right  from  the  side.      (Nuttall  and  Shipley.) 

feathery  antennae,  while  in  the  female,  as  a  rule,  these  organs 
i  are  slender,  thread-like,  and  covered  with  short  lateral  hairs. 
i  Subfamily  Anophelin^e.  —  Mosquitoes  with  straight 
:  proboscis;  palpi  long  in  both  sexes;  occiput  mostly  with 

upright,  forked  scales,  never  with  flat,  lateral  scales.    Thorax 


Fig.  26. — Raft  of  culicine  eggs.     (Sambon.) 


with  scales  or  hairs;  scutellum  not  trilobed;  postscutellum 
nude;  abdomen  with  scales  or  hairs.  Eggs  are  laid  singly 
and  not  in  rafts.  Larvae  without  respiratory  siphon.  Adult 
assumes  characteristic  resting  position. 


138 


SANITATION  FOR  MEDICAL  OFFICERS 


The  anopheles  contain  about  eighteen  genera,  of  which 
only  two  are  of  medical  interest.  In  both  of  these  genera  the 
first  submarginal  cell  is  large ;  antennal  segments  with  lateral 
scale  tufts;  thorax  and  abdomen  with  hair-hke  curved  scales. 
No  flat  scales  on  the  head.  Basal  lobe  of  male  genitaUa 
consists  of  one  segment. 

Genus  Anopheles.    Wing  scales  large  and  lanceolate. 

Genus  Myzomyia.  Wing  scales  mostly  small,  long,  and 
narrow. 

Species  Concerned  in  the  Transmission  of  Malaria. — No 
anopheline  mosquito  should  be  trusted,  but  comparatively 
few  species  have  been  actually  demonstrated  to  transmit 
malaria.     It  must  always  be  remembered  that  while  many 


Fig.  27.. — The  occiput  and  scutellum  of  an  anopheline  mosquito  to 
show  the  scale  characters.  At  the  side  is  seen  the  lateral  aspect  of  the 
vertical  scales.     (Theobald.) 


species  may  become  infected  in  the  laboratory,  that  in  a  given 
locality  usually  only  one  or  at  most  several  species  are  con- 
cerned in  the  transmission  of  the  disease.  These  species  are 
suitable  hosts  for  the  parasite,  become  infected  in  practi- 
cally 100  per  cent,  of  cases,  and  the  parasite  practically  always 
finishes  its  full  cycle  of  development  in  this  mosquito.    Other 


I 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     139 

species  become  infected  in  possibly  lo  per  cent,  of  cases,  and 
the  parasite  completes  its  life  cycle  in  only  a  few  of  these. 
Of  the  few  that  become  infective  the  chances  are  that  they 
die  or  never  succeed  in  biting  man  again,  so  that  while  such 
species  may  be  shown  to  be  capable  of  transmitting  the 
disease  in  the  laboratory,  they  are  not  actually  transmitters 


'^ 


Fig.  28. — Larva  of  C.  hangs  nearly  at  right  angles  to  water  surface. 

(Park.) 

of  the  disease  in  nature.  A.  quadrimaculatus,  A.  crucians 
and  A.  punctipennis  are  the  most  dangerous  North  American 
species.  A.  albimanus  and  A.  argyritarsus  are  the  most 
important  species  for  Central  America.  In  the  Canal  Zone, 
A.  albimanus  is  the  principal  carrier.    Darling  found  that  it 


Fig.  29, — Larva  of  A.  are  parallel  to  surface.     (Park.) 

becomes  infected  in  70  per  cent,  of  experimental  cases,  and 
it  enters  houses  freely  through  screens  and  doors  and  is 
carried  in  on  clothing.  In  the  Southern  States,  A.  quadri- 
maculatus is  probably  the  principal  carrier  of  malaria.  A. 
maculipennis  is  the  most  important  European  species. 
Myzomyia  funesta  or  Christophersi,  and  called  by  Walker 


140 


SANITATION  FOR  MEDICAL  OFFICERS 


and  Barber  Myzomyia  febrifera,  is  apparently  the  mosquito 
mainly  concerned  in  the  transmission  of  malaria  in  the 
Philippines. 

Not  all  species  of  anopheles  carry  all  forms  of  the  malarial 
parasite  equally.  Thus  A.  crucians  is  a  most  important 
carrier  of  the  estivo-autumnal  parasite,  but  is  said  not  to 
transmit  other  forms  of  malaria. 

The  important  point  in  this  for  the  sanitary  officer  is  that 
he  should  determine  what  mosquito  is  responsible  for  the 
transmission  of  disease  in  his  locahty,  and  then  should  learn 
everything  possible  about  the  habits  of  that  particular  mos- 
quito in  order  that  he  may  direct  an  intelligent  campaign 
against  it.  If  that  mosquito  is  breeding  about  the  house  it 
will  do  no  good  to  carry  out  extensive  drainage  operations. 
The  particular  mosquito  at  fault  can  usually  be  identified 
very  easily  by  an  expert,  and  for  this  purpose  the  assistance 


Fig.  30  — Head  and  scutellum  of  Stegomyia,  to  show  scales.     (Theobald.) 


of  an  expert  entomologist  should  be  secured  whenever  pos- 
sible. When  this  is  not  possible,  collect  samples  of  mosquitoes 
taken  at  various  hours  of  the  day  and  night,  place  them  in 
labeled  pill  boxes,  adding  a  single  small  drop  of  formaldehyde 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     141 


to  the  cotton  as  a  preservative,  and  send  them  by  mail  to 
the  Army  Medical  School,  Washington,  D.  C,  for  identifi- 
cation. Identification  of  the  mosquito  often  affords  definite 
information  with  regard  to  the  probable  location  of  breeding 
places. 

Subfamily  Culicin^. — Mosquitoes  with  straight  pro- 
boscis, long  palpi  in  the  male,  but  short  in  the  female; 
Scutellum  trilobed,  postscutellum  nude;  wings  with  long 
first  submarginal  cell,  and  without  a  third  anal  vein.    Larvae 


Fig.  31. — Head  and  scutellum  of  Culex,  to  show  scales.     (Theobald.) 

with  respiratory  siphons.  Eggs  usually  laid  in  masses.  There 
are  upward  of  sixty- three  genera,  but  of  these  only  three, 
Stegomyia,  Culex,  and  Mansonia,  are  of  medical  importance. 

1.  Genus  Stegomyia. — Culicinae,  with  head  and  scutellum 
clothed  with  flat  scales,  with  a  few  upright  forked  scales 
interspersed.  (Scales  may  be  examined  by  mounting  the 
mosquito  on  a  slender  pin  and  holding  it  under  the  micro- 
scope; the  two-third  objective  should  be  used.)  Stegomyia 
fasciata  (calopus)  transmits  yellow  fever,  and  some  experi- 
ments indicate  that  it  also  transmits  dengue. 

2.  Genus  Culex. — Occiput  covered  with  flat  scales  at  the 


142  SANITATION  FOR  MEDICAL  OFFICERS 

sides,  and  mixed  upright  forked  scales  and  narrow  curved 
scales  in  the  middle;  thorax  and  scutellum  with  hair-like 
curved  scales  or  narrow  curved  scales.  Culex  fatigans  is  a 
probable  transmitter  of  dengue. 

3.  Genus  Mansonia. — Common  in  the  Philippines  and  in 
Panama.  The  scales  on  the  head  and  thorax  are  the  same  as 
in  Culex.  The  wdng  scales,  however,  are  very  thick,  broad 
and  truncated,  so  that  it  looks  like  a  mosquito  covered  with 
mildew.  M.  uniformis  and  M.  africanus  are  found  in  the 
Philippines,  and  breed  chiefly  in  marshes,  but  may  breed 
in  the  water  at  the  base  of  banana  leaves.  M.  tililans  is 
common  in  Panama.  It  breeds  at  the  rootlets  of  the  water 
lettuce,  from  which  they  obtain  their  air,  so  that  neither 
larva  nor  pupa  is  compelled  to  come  to  the  surface  to  breathe. 
Oiling  does  not  destroy  them,  but  they  may  be  killed  by 
larv^acides  that  diffuse  in  the  water.  M.  uniformis  carries 
Filaria  bancrofti,  but  no  other  disease  so  far  as  kno\Mi. 

Life  Cycle. — A  mosquito  passes  through  a  compHcated  life 
cycle  with  a  complete  metamorphosis,  including  the  egg,  the 
larva,  the  pupa,  and  the  perfect  insect  or  imago.  Soon  after 
the  female  is  liberated  from  the  pupa  case  it  is  fertilized. 
The  eggs  are  not  laid  until  after  a  meal  of  blood,  which  seems 
to  be  necessary  for  the  development  of  the  eggs.  About 
100  eggs  are  laid  early  in  the  morning  upon  the  surface  of  the 
water,  the  arrangement  of  the  eggs  varying  in  different 
species.  In  from  tw^o  to  three  days  the  larva  escapes  from 
the  egg  and  grows  rapidly.  These  larvae  are  very  character- 
istic, and  are  popularly  known  as  wigglers.  They  come  up 
to  the  surface  to  breathe,  w^here  the  position  assumed  by  the 
larva  is  also  characteristic;  anopheUne  larvae  have  no  long 
respiratory  siphon,  and  lie  parallel  to  the  surface  while  culi- 
cine  larvae  hang  head  downward  from  the  surface.  When 
disturbed  they  swim  to  the  bottom  by  jerks.  The  duration 
of  the  larval  stage  varies  with  food  and  temperature,  and 
niay  be  from  eleven  tg  twenty-one  days  or  longer  under 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     143 

unfavorable  conditions.  The  larva  then  goes  into  a  resting 
stage  or  pupa  which  lasts  about  forty-eight  hours,  during 
which  time  the  transformation  to  the  adult  mosquito  occurs. 
Pupae  do  not  eat  but  must  come  to  the  surface  to  breathe. 
When  the  development  is  complete  the  pupa  comes  to  the 
surface  of  the  water,  the  dorsal  portion  of  the  thorax  splits 
open,  and  the  adult  insect  emerges,  dries  its  wings  while 
supported  on  the  pupa  case,  and  flies  away.  Oiling  kills  the 
larvae  because  they  are  unable  to  project  the  gij^hon  through 
the  film  of  oil  and  therefore  cannot  breathe. 

The  adult  insects  generally  bite  at  night,  and  this  is  par- 
ticularly true  of  anopheUne  mosquitoes,  hence  the  bad  repu- 
tation that  night  air  formerly  had.  Stegomyia,  on  the  con- 
trary, bites  freely  during  the  daytime.  It  is  very  quick  and 
active,  and  is  very  erratic  in  its  flight,  so  that  it  is  very  diffi- 
cult to  catch.  In  yellow  fever  countries  great  care  must  be 
taken  to  avoid  being  bitten  by  this  mosquito. 

It  is  not  known  exactly  how  long  mosquitoes  live,  but  it  is 
known  that  both  adults  and  larvae  can  hibernate  and  five 
over  until  the  next  season.  Eggs  may  be  dried  for  several 
years  and  still  hatch  out. 

Flight  of  Mosquitoes. — It  is  usually  supposed  that  mos- 
quitoes do  not  fly  far  from  their  breeding  place,  and  no  doubt 
this  is  a  general  rule  for  many  species. .  The  Stegomyia  par- 
ticularly tends  to  remain  about  the  houses  where  it  originated, 
and  thus  in  the  days  before  the  transmission  of  the  disease 
was  understood,  certain  houses  came  to  be  known  as  yellow 
fever  foci.  But  Le  Prince  has  shown  thait  A.  quadrimacu- 
latus  may  fly  as  far  as  a  mile  from  its  breeding  place,  and 
that  they  can  cross  a  river  of  800  feet  width.  Such  possibili- 
ties must  always  be  kept  in  mind,  and  while  it  is  always  best 
to  look  first  for  breeding  places  nearby,  when  mosquitoes  are 
abundant  and  these  nearby  breeding  places  cannot  be  found 
the  ground  must  be  thoroughly  studied  over  a  considerable 
area. 


144  SANITATION  FOR  MEDICAL  OFFICERS 

Sanitary  Measures. — I.  Reduction  of  Number  of  Mosqui- 
toes to  the  Point  where  Infection  Will  Not  Be  Transmitted. 

Methods  Directed  against  the  Adult  Insect. — i.  Clear 
away  all  dense  vegetation.  This  deprives  the  insect  of 
shelter  and  exposes  possible  breeding  places.  In  the  Canal 
Zone  all  vegetation  was  removed  for  200  yards  around  all 
habitations. 

2.  Fumigation  of  rooms,  especially  those  from  which 
patients  are  removed. 

3.  Destruction  by  traps,  swatters,  etc.  Even  in  a  screened 
building  daily  inspection  is  recommended  to  kill  adult  insects 
that  have  entered.  Many  methods  for  killing  mosquitoes 
are  recommended.  In  the  Philippines  the  following  device 
has  proved  effective.  Take  a  piece  of  medium- weight  wire 
and  bend  it  in  the  form  of  a  tennis  racquet,  but  much 
smaller.  Twist  this  through  a  hea\y  spider  web  and  apply 
it  gently  over  mosquitoes  on  the  wall.  The  mosquitoes  fly 
into  the  spider  web  and  are  caught.  Le  Prince  used  mosquito 
traps  in  Panama,  where  a  trap  might  catch  several  hundred 
mosquitoes  a  night.  When  catching  mosquitoes  for  study 
or  identification  use  the  following  killing  tube.  Take  a  camel- 
hair  brush-tube,  or  a  large  test-tube,  and  pack  the  bottom 
with  an  inch  layer  of  small  rubber  bands.  Hold  in  place  by 
a  plug  of  absorbent  cotton  and  a  disk  of  blotting  paper. 
Pour  in  a  few  cubic  centimeters  of  chloroform  and  cork  tightly. 
The  chloroform  is  absorbed  by  the  rubber  bands  and  the 
tube  will  remain  effective  for  several  days,  the  chloroform 
killing  the  insect  when  the  tube  is  placed  over  it. 

II.  Methods  Directed  against  the  Larva. — i.  Engineering 
Works. — Draining  of  swamps  and  roads,  training  streams, 
ditching. 

2.  Organization  of  mosquito  brigades  under  trained  super- 
visors who  remove  all  small  collections  of  water,  spray,  and 
oil  other  collections  every  ten  days,  screen  wells,  cesspools, 
and  cisterns,  keep  streams  and  drains  free  of  water  plants. 


I 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     145 

etc.  All  gutters  of  houses  and  bamboo  joints  to  be  properly 
drained.  A  search  is  maintained  in  all  possible  pjaces  for 
larvse  and  all  breeding  places  destroyed.  Special  attention 
should  be  paid  to  tin  cans,  broken  bottles,  flower  pots,  etc. 

III.  Reduction  in  the  Number  qf  Bites. — Even  though  mos- 
quitoes are  numerous,  they  cannot  become  infected  unless 
they  can  bite  a  patient  having  malaria,  and  they  must  bite 
again  to  transmit  the  infection.    Therefore: 

1.  Screen  all  Malarial  Patients. — Such  patients  should  be 
kept  in  a  properly  screened  ward  with  a  double  door,  and  in 
addition  should  sleep  under  a  bed  net,  since  a  few  mosquitoes 
may  gain  access  even  to  a  screened  building. 

2.  Use  Screening  Generally. — Screen  beds,  houses,  and  in 
malarial  districts,  sentries  and  all  men  obliged  to  remain 
out  at  night  should  protect  themselves  by  wearing  headnets, 
gauntlets,  etc.  Inspect  screening  daily  to  be  sure  it  is 
effective. 

3.  The  Use  of  Protective  Oils. — Oil  of  citronella  will  keep 
mosquitoes  from  biting  if  appUed  frequently  enough,  but  it 
evaporates  rapidly.  Smudges  may  also  be  used.  Such 
methods  are  not  of  much  value  except  at  such  times  and 
places  when  the  other  methods  outlined  above  cannot  be 
carried  out. 

IV.  All  of  these  measures  must  be  combined  with  educa- 
tion by  means  of  lectures  or  informal  talks,  and  the  use  of 
mosquito  bars  must  be  enforced  by  a  post  or  camp  order, 
followed  by  inspections  to  make  sure  the  order  is  obeyed. 
The  average  soldier  does  not  understand  the  transmission 
of  malaria,  and  may  think  the  regulations  foolish  or  unneces- 
sary. The  good  soldier  will  obey  the  orders  on  principle,  but 
the  sanitary  officer  must  be  prepared  to  deal  vrith  chronic 
offenders  who  refuse  to  use  mosquito  bars.  Some  must  be 
tried.  Much  trouble  will  be  avoided,  and  active  cooperation 
may  be  secured  on  the  part  of  non-commissioned  officers 
and  others  if  the  men  are  instructed  on  the  part  played  by  the 

10 


146  SANITATION  FOR  MEDICAL  OFFICERS 

mosquito  in  the  transmission  of  malaria  and  the  necessity 
of  avoiding  being  bitten,  particularly  at  night.  More  care 
w"ll  be  taken  to  avoid  injury  to  the  screening  of  buildings, 
and  many  men  may  be  trained  to  search  the  barracks  for 
anophelinae  in  the  morning.  Any  soldier  may  be  trained  to 
recognize  an  anopheles  by  showing  him  the  characteristic 
posture  of  this  mosquito  on  the  walls,  and  they  should  be 
taught  to  look  for  them  in  the  dark  corners,  under  lavatories, 
and  similar  places  where  this  mosquito  hides  during  the  day. 

Fumigation  of  Rooms. — Sulphur  is  best  when  it  can  be  used, 
for  it  kills  mosquitoes.  It  must  be  remembered  that  sulphur 
dioxide  injures  most  metallic  substances  and  fabrics, and  these 
should  be  removed  before  fumigation.  To  determine  the 
amount  of  sulphur  to  be  burned,  divide  the  cubic  feet  by  500, 
reading  the  result  in  pounds.  A  room  40  +  20  +  12  would 
contain  9600  cubic  feet,  so  that  19.2  pounds  of  sulphur  should 
be  burned.  Use  strict  precautions  against  fire.  It  is  difficult 
to  start  sulphur  burning.  Put  a  little  pyrethrum  on  top, 
add  alcohol  to  this,  and  light. 

When  sulphur  cannot  be  used,  pyrethrum  may  be  used. 
Burn  I  pound  of  pyrethrum  to  each  1000  cubic  feet.  The 
mosquitoes  are  stupefied  but  not  killed,  and  must  be  swept 
up  afterward  and  burned.  Tobacco  stems  2  pounds  to  1000 
cubic  feet,  may  be  used,  or  camphor  i  part,  phenol  3  parts, 
using  I  ounce  of  this  mixture  for  each  1000  cubic  feet.  Sweep 
up  mosquitoes  and  destroy  when  all  of  these  preparations 
are  used  except  sulphur. 

Mosquito  Traps. — Have  been  used  extensively  in  the  canal 
zone.  The  trap  consists  of  a  half-cylinder  of  wire  netting, 
having  two  ridges  inside  it,  the  apices  of  which  are  perforated 
by  longitudinal  slits  about  J  inch  wide  and  3  inches  long. 
Through  the  slits  in  these  ridges  the  mosquitoes  enter  the 
chamber  of  the  trap  and  cannot  find  their  w^ay  out  again. 
The  traps  are  so  placed  as  to  catch  mosquitoes  entering  a 
building.    In  the  Canal  Zone  it  was  found  that  more  ano- 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     147 

phelines  were  caught  if  the  traps  were  placed  in  the  lee  of  the 
building,  while  more  culicines  were  caught  if  the  traps  were 
installed  on  the  windward  side  of  the  building. 

Ditching.— SrmW  accumulations  of  water  may  be  lemoved 
by  filling,  but  all  large  breeding  places  for  mosquitoes  should 
be  drained  if  possible.  There  are  several  methods  of  drain- 
age, the  choice  of  which  must  depend  upon  relative  cost  and 
the  circumstances  of  time  and  place. 

1.  Open  Ditches.— Maij  be  satisfactory  if  there  be  enough 
slope  to  give  a  swift  current;  otherwise  they  become  clogged 
mth  algae,  and  furnish  a  breeding  place,  so  that  they  must 
be  kept  open,  cleaned  and  oiled  weekly.  The  method  is 
unsatisfactory  and  costly  from  the  continuous  employment 
of  labor. 

2.  Blind  Drains. — Recommended  if  better  cannot  be  ob- 
tained. A  culvert  is  made  and  lined  with  flat  stones  and  filled 
with  first  large,  then  small  stones.  A  good  grade  is  essential. 
It  may  become  blocked,  but  does  not  harbor  anopheles. 

3.  Cement-lined  Open  Drain. — Only  form  that  should  be 
adopted  in  the  tropics  and  should  have  a  considerable  grade. 
It  is  semicircular  in  shape.  If  there  is  a  good  grade,  they  will 
keep  themselves  clean  by  flushing. 

4.  Subsoil  Drainage  with  Tiles.— Le  Prince  says  it  is  most 
economical  and  permanent  method  of  destroying  anopheles 
in  the  tropics.    It  costs  from  16  to  20  cents  a  foot  or  more, 

!  depending  upon  the  locality.  It  is  recommended  that  they 
\  should  not  have  a  flatter  grade  than  0.5  per  cent.,  while  as 
j  high  as  5  per  cent,  gave  perfect  satisfaction  if  the  tiles  were 
\  covered  with  plenty  of  stone  to  hold  them  in  place.  If  any 
j  considerable  amount  of  drainage  is  to  be  constructed  the 
I  assistance  of  an  engineer  should  be  secured. 

Oiling. — Oil  kills  mosquito  larvae  by  forming  a  surface 
film  through  which  they  cannot  project  the  respiratory 
siphon.  Accumulations  of  water  that  cannot  be  drained  may 
be  oiled.    Any  crude  petroleum  may  be  used,  but  experience 

li 


148  SANITATION  FOR  MEDICAL  OFFICERS 

has  shown  that  the  best  results  are  obtained  with  oils  of 
certain  grades.  If  4  parts  oil  of  18  degrees  gravity  be  mixed 
with  I  part  of  34  degrees  gravity  the  resulting  mixture  will 
remain  efficient  for  three  or  four  wxeks  after  application. 
The  temperature  and  sun  make  many  variations  as  well  as 
the  grade  of  oil.  Since  the  life  of  the  larvae  is  from  ten  to 
fourteen  days  the  most  sensible  rule  would  be  to  reoil  every 
two  weeks.  The  exact  interval  should  be  determined  by 
inspections.  The  oil  may  be  applied  by  a  force  pump  and  a 
straight  nozzle  for  large  bodies  of  water,  and  a  spray  nozzle^ 
for  small  accumulations  of  water.  Care  should  be  taken  to  see 
that  there  are  no  portions  of  the  surface  left  uncovered  by  oil. 
Larvacide. — Where  there  is  considerable  rainfall  oil  may  be 
rapidly  sw^ept  aw^ay,  and,  moreover,  there  is  one  species, 
Mansonia  titilans,  which  is  not  killed  by  oil,  as  it  does  not  come 
to  the  surface  but  gets  its  air  from  the  roots  of  water  plants. 
Under  these  circumstances  the  following  larvacide,  which  was 
extensively  used  on  the  Canal  Zone,  may  be  recommended: 
150  gallons  of  crude  carbolic  acid  (specific  gravity  not  greater 
than  0.97  and  to  contain  not  less  than  30  per  cent,  tar  acids) 
are  heated  in  an  iron  tank  having  a  steam  coil  with  steam  at 
50  pounds  pressure;  200  pounds  of  finely  crushed  and  sifted 
common  rosin  are  dissolved  in  the  heated  acid,  and  then  30 
pounds  of  caustic  soda,  dissolved  in  6  gallons  of  water,  are 
added.  There  is  a  mechanical  stirring  rod  attached  to  the 
tank.  The  product  is  ready  in  a  few  minutes,  yielding  about 
3 1  barrels.  It  is  necessary  to  keep  the  specific  gravity  of  the 
product  approximately  that  of  water  so  that  it  will  diffuse 
rapidly  and  neither  remain  on  top  or  sink  to  the  bottom. 
About  200  barrels  a  month  were  used  in  Panama  to  treat  100 
square  miles  of  territory.  Before  using  as  a  spray  i  gallon 
may  be  diluted  to  6  gallons  with  water,  and  the  resultant 
mixture  may  be  sprayed  over  accumulations  of  water.  One 

'  A  knapsack  spray  pump  for  oiling  small  accumulations  of  standmg 
water  is  made  by  F.  E.  Myers  &  Bros.,  Ashland,  Ohio. 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     149 

k 

part  emulsion  to  5000  parts  of  water  will  kill  anopheles 
larvae  in  from  five  to  ten  minutes.  In  addition,  larvacide 
kills  the  algae  and  thus  destroys  the  food  and  hiding  placer  of 
the  larvae.  It  is  also  a  good  disinfectant,  having  a  Rideal- 
Walker  coefficient  of  from  2  to  5. 

I  Disadvantages. — It  does  not  emulsify  and  is  inert  in  brackish 
w^ater.  It  deteriorates  on  exposure  to  air  and  must  be  kept 
in  kegs.    It  loses  toxicity  rapidly  when  mixed  with  water. 

1  Cost. — On  the  Isthmus,  its  cost  varied  from  14  to  17  cents 
a  gallon. 

Screening. — Screening  material  should  be  composed  of 
copper  when  possible.  Iron  screening  is  not  durable  and, 
costs  more  in  the  end.  If  iron  be  used  it  must  be  painted. 
For  anopheles,  sixteen  meshes  to  the  linear  inch  is  sufficient, 
but  to  exclude  stegomyia,  eighteen  meshes  to  the  linear  inch 
is  necessary.  Such  screening  in  the  past  cost  50  cents  per 
square  yard.  In  temporary  quarters  where  such  expenditure 
would  not  be  justified,  quarters  may  be  screened  with  ordi- 
nary cotton  mosquito  netting  or  with  a  cheap  grade  of  lawn. 

,  Le  Prince  states  that  the  screening  of  dwellings  alone  reduces 

'  the  malarial  rate  at  least  one  third. 

Mosquito  Bars,  Headnets. — These  appliances  are  issued  by 
the  Quartermaster's  Department,  and  mosquito  bars  are 
also  issued  by  the  Medical  Department  for  hospital  use. 
When  in  malarial  districts,  medical  officers  should  insist 
that  troops  be  supplied  with  these  articles.  The  mosquito 
bar  now  issued  can  be  used  eithe'r  on  the  bunk  or  in  the  shelter 
tent,  and  in  malarial  districts  the  troops  should  be  ordered 
to  carry  them  in  the  field,  and  compelled  to  use  them  in  the 
shelter  tents. 

Antimosquito  Work  in  Cantonments. — Le  Prince  states  that 
five  areas  require  control  measures. 

1.  A  strip  of  land  one  mile  wide  surrounding  the  canton- 
ment, from  which  anopheles  could  reach  the  cantonment. 

2.  The  inhabited  area  between  the  military  reservation  and 
the  nearest  town  or  village. 


150  SANITATION  FOR  MEDICAL  OFFICERS 

3.  The  town  near  the  cantonment  which  soldiers  visit. 

4.  A  strip  of  land  surrounding  this  town  from  which 
anopheles  could  enter  it. 

5.  Amusement  parks  and  other  places  that  the  men  would 
probably  visit  after  sundown. 

The  work  outside  the  cantonment  lines  is  carried  out  by 
cooperation  with  the  civil  authorities. 

INSECT  PESTS. 

Many  insects  are  a  nuisance  even  though  not  transmitting 
disease.  The  following  methods  may  be  used  in  ridding 
barracks  and  quarters  of  these  pests : 

Cockroaches. — One  of  the  most  effective  means  of  ridding 
premises  of  roaches  is  dusting  with  commercial  sodium 
fluoride,  either  pure  or  diluted  one-half  with  powdered  gypsum 
or  flour.  By  using  a  blower  this  powder  can  be  thoroughly 
dusted  into  the  runways  and  hiding  places  of  the  roaches. 
Borax  can  also  be  used  in  the  same  way.  When  very  numerous 
a  six-hour  fumigation,  using  4  pounds  of  sulphur  per  1000 
cubic  feet  or  one  hour  with  hydrocyanic  gas,  using  10  ounces 
per  1000  cubic  feet,  is  effective. 

Ants. — The  only  satisfactory  method  to  control  this  pest 
is  by  the  use  of  a  poisoned  bait.  A  formaldehyde  solution 
prepared  as  described  for  the  house  fly  may  be  effective.  The 
following  bait  is  recommended  by  Dr.  W.  Dwight  Pierce,  of 
the  Bureau  of  Entomology:  Prepare  a  syrup  of  granulated 
sugar  15  pounds,  water  7  pints  and  one-fourth  ounce  of 
tartaric  acid  crystals.  Boil  for  thirty  minutes  and  cool. 
Dissolve  three-fourths  of  an  ounce  of  sodium  arsenite  (C.  P.) 
in  one  pint  of  hot  water.  Mix  the  poison  solution  with  the 
syrup  and  add  one  and  one-half  pounds  of  honey.  Mix  well. 
This  syru]:)  may  be  put  in  paraffined  bags  or  tin  cans  and 
tacked  on  the  sides  of  buildings  where  the  ant  runways  enter. 

Bed-bugs   {Cimex  lectularius). — This  is  often  a  serious 


INSECTS  CONCERNED  IN  TRANSMISSION  OF  DISEASE     151 

pest  in  camps  and  barracks.     Its  normal  food  is  human 
blood,  and  it  may  transmit  kala  azar  and  relapsing  fever. 

The  following  method  was  used  successfully  in  the  Canal 
Zone  for  treating  cots.  Dip  the  cots  bodily  in  a  tank  con- 
taining a  solution  of  caustic  soda  of  the  strength  usually 
employed  in  washing  clothes,  and  allow  them  to  remain 
fifteen  minutes.  This  will  penetrate  the  crevices  of  the  wood- 
work and  canvas  and  destroy  both  bugs  and  eggs.  On 
removal  cots  should  be  well  washed  with  a  hose  to  remove 
the  soda,  and  exposed  to  sun  and  air  until  dry.  Where  this 
method  cannot  be  used,  kerosene  or  benzine  should  be  used 
liberally  on  those  parts  of  the  cot  that  may  harbor  the  insects. 
Folds  and  seams  of  tents  and  cracks  in  wooden  flooring  must 
also  receive  attention.    This  should  be  repeated  several  times. 

For  infected  barracks  fumigation  is  the  most  effective 
method  of  treatment.  Sulphur  may  be  used  at  the  rate  of 
5  pounds  per  looo  cubic  feet,  or  cyanide  fumigation  may  be 
used  at  the  rate  of  5  ounces  of  potassium  cyanide  per  1000 
cubic  feet. 

Fumigation  with  Cyanide  Gas. — This  method  is  rapid  and 
very  efficient  against  all  forms  of  insect  life,  and  is  not 
dangerous  when  conducted  by  a  trained  personnel.  It  should 
not  be  attempted  by  an  untrained  personnel  except  under 
the  supervision  of  a  medical  officer.  The  gas  is  generated 
by  the  addition  of  sulphuric  acid  to  potassium  or  sodium 
cyanide.  It  is  safely  handled  as  follows:  Place  in  a  jar  or 
barrel  two  parts  of  acid  and  two  and  one-half  parts  of  water 
to  every  part  of  cyanide  to  be  used.  Hang  the  cyanide  in  a 
package  suspended  over  the  jar  so  that  it  can  be  released  by 
the  operator  outside  the  building  by  pulling  or  releasing  the 
cord.  All  cracks  should  have  been  previously  sealed.  When 
the  necessary  period  of  fumigation  is.  over,  all  doors  and 
windows  should  be  opened  from  the  outside,  and  the  building 
thoroughly  aired  before  it  is  entered.  Ten  ounces  of  cyanide 
per  1000  cubic  feet  will  kill  lice  and  all  bed-bugs,  fleas  and 
cockroaches. 


NOTES  ON  TRANSMISSIBLE   DISEASES. 


REPORTS    OF    EPIDEMIC    DISEASES    (MANUAL    OF    MEDICAL 

DEPARTMENT). 

On  the  appearance  of  the  first  recognized  case  of  typhoid 
fever,  paratyphoid  fever,  smallpox,  measles,  diphtheria, 
cerebrospinal  meningitis,  or  other  epidemic  disease  at  or 
near  a  military  post  or  station  the  senior  medical  officer  will 
at  once  report  the  same,  and  the  nature  and  extent  of  the 
epidemic,  as  far  as  it  has  developed,  to  the  commanding 
officer,  sending  at  the  same  time  a  duplicate  report  direct  to 
the  department  surgeon  and  a  triplicate  direct  to  the  Surgeon- 
General.  Should  the  outbreak  occur  in  a  command  en  route 
to  a  new  station,  whether  by  marching,  by  rail,  or  by  water, 
the  medical  officer  will  make  a  similar  report  in  triplicate, 
and  will  in  addition  send  a  quadruplicate  direct  to  the 
surgeon  of  the  new  station. 

The  continuance  of  the  epidemic,  its  progress  and  decline, 
its  origin  or  importation,  the  measures  taken  for  its  suppres- 
sion, the  number  of  cases,  the  number  of  deaths  and  recov- 
eries, and  such  other  information  in  relation  thereto  as  may 
be  important  and  interesting  will  be  noted  from  month  to 
month  in  the  sanitary  reports  (form  50). 

The  senior  medical  officer  of  a  miUtary  post  will  promptly 
notify  the  local  board  of  health,  if  there  is  one,  of  all  cases  of 
infectious  disease  occurring  at  the  post  of  which  such  board 
would  take  cognizance  were  the  same  to  occur  in  the  com- 
munity subject  to  its  supervision. 

(152) 


NOTES  ON  TRANSMISSIBLE  DISEASES  153 

Statistics  as  an  Index  or  Sanitary  Conditions. — 
Certain  statistics  serve  as  an  indication  of  the  prevalence 
of  disease.  Every  sanitary  officer  wishes  to  know  not  only 
the  incidence  of  each  disease  in  the  camp  for  which  he  is 
responsible,  but  also  how  his  rates  compare  with  those  in 
other  camps.  Each  disease  has  what  may  be  called  a  normal 
rate  of  incidence.  Any  sudden  increase  over  this  normal 
rate,  especially  when  the  rate  for  other  camps  for  this  same 
disease  shows  no  corresponding  increase,  serves  to  indicate 
the  necessity  for  an  investigation  to  determine  the  reason  for 
this  increased  incidence  and  sanitary  inspections  should  be 
made  with  this  end  in  view.  The  two  most  useful  and  gener- 
ally used  rates  are  the  admission  rate  and  the  non-effective 
rate.  The  admission  rate  is  the  most  important  as  a  sanitary 
guide,  for  it  is  based  on  the  actual  number  of  cases.  The  non- 
effective rate  is  influenced  by  the  character  of  the  disease, 
the  nature  of  the  treatment  received  and  other  factors.  The 
admission  rate  is  therefore  used  to  show  the  progress  of  an 
epidemic,  or  the  results  of  measures  taken  to  check  it,  while 
the  non-effective  rate  showing  the  number  of  men  daily 
incapacitated,  affords  valuable  military  information,  and  the 
lowering  of  this  rate  indicates  the  number  of  men  who  are 
saved  as  effectives  of  the  army  through  the  efficiency  of  the 
Medical  Department. 

The  Admission  Rate. — As  used  by  the  Census  reports  this 
rate  is  per  100,000  population.  As  used  in  the  annual  reports 
and  bulletins  from  the  Surgeon- General's  Office,  and  generally 
in  the  Army,  it  is  always  expressed  per  1000  of  strength.  It 
is  a  yearly  rate,  so  that  an  admission  rate  of  900  means  that 
for  every  thousand  men  in  the  command,  900  were  admitted 
in  the  course  of  the  year.  To  obtain  this  rate,  the  total 
number  of  admissions  for  the  year  is  divided  by  the  number 
of  thousands  of  the  strength  of  the  command  for  the  year. 
In  order  to  obtain  this  rate  for  a  given  week  or  month,  the 
total  number  of  admissions  for  the  week  or  month  is  divided 


154  SANITATION  FOR  MEDICAL  OFFICERS 

by  the  number  of  thousands  of  strength  of  the  command  for 
that  week  or  month,  and  this  figure  is  multipUed  by  52  when 
based  on  figures  of  a  week,  or  by  12  when  based  on  the  figures 
of  a  month. 

The  Non-efective  Rate. — As  used  in  the  reports  of  the 
Surgeon-General,  this  indicates  the  total  daily  number  of 
sick  in  proportion  to  the  strength  of  the  command.  To 
obtain  this  rate   the  following  formula  may  be  used. 

Total  number  days'  sickness  for  the  year  1000 


365  average  strength  of  command 

Should  it  be  desired  to  learn  the  non-effective  rate  for  any 
given  week  or  month,  the  total  number  of  days  lost  is  multi- 
plied by  52  if  for  a  week,  and  by  12  if  for  a  month,  and  the 
yearly  days  lost  so  obtained  are  used  in  the  above  formula. 

Both  of  these  rates  are  made  possible  by  the  data  furnished 
on  the  sick  and  wounded  cards  for  the  month,  and  these 
cards  also  furnish  information  necessary  to  do  justice  to 
both  the  man  and  the  government.  The  making  of  such 
records  is  called  ''red  tape"  by  the  uninstructed,  but  the  great 
value  of  the  statistics  so  compiled  should  be  obvious. 

THE  SOURCES  AND  MODES  OF  INFECTION.^ 

I.  Life  of  Disease  Germs  Outside  the  Body. — While 
it  is  possible  that  anthrax,  tetanus,  and  pus  organisms  may 
develop  in  the  soil,  there  is  no  evidence  that  they  commonly 
do  so.  Typhoid,  cholera,  dysentery,  and  plague  may  main- 
tain a  limited  saprophytic  existence,  but  this  is  probably 
quite  unusual.  In  temperate  climates,  such  a  source  for  there 
diseases  must  be  an  almost  infinitesimal  factor  in  their 
development.  Probably  the  diphtheria  bacillus  never  has  a 
saprophytic  growth  of  any  significance,  except  possibly  very 

1  Chapin,  191  o,  Wiley  &  Sons. 


NOTES  ON  TRANSMISSIBLE  DISEASES  155 

rarely  in  milk.  As  for  tuberculosis,  pneumonia,  influenza, 
meningitis,  scarlet  fever,  typhus,  smallpox,  whooping-cough, 
gonorrhea  and  syphilis,  malaria,  yellow  fever,  etc.,  there  is 
not  the  slightest  reason  for  supposing  that  they  ever  develop 
outside  the  bodies  of  animals.  These  facts  all  point  toward 
the  relative  importance  of  human  agencies  in  the  spread  of 
disease,  and  of  insect  transmission,  and  toward  the  relative 
unimportance  of  fomites  in  the  transmission  of  disease. 

II.  Carriers  and  Missed  Cases. — i.  Mild  atypical  and 
unrecognized  cases  of  the  infectious  diseases  are  often 
extremely  common.  In  many  diseases  they  may  be  more 
numerous  than  the  recognized  cases. 

2.  Disease-producing  microorganisms,  whether  bacteria  or 
protozoa,  frequently  persist  in  the  body  without  causing 
symptoms. 

3.  These  germs  may  remain  for  weeks,  months,  years,  or 
for  hfe.  Sometimes  these  carriers  give  no  history  of  ever 
having  been  sick. 

4.  While  the  bacteria  found  in  carriers  may  be  avirulent, 
they  are  often  very  virulent. 

5.  There  is  ample  epidemiological  evidence  that  healthy 
carriers  as  well  as  mild,  unrecognized  cases  are  the  source 
of  well-marked  outbreaks. 

6.  The  number  of  carriers  varies  greatly  in  different  dis- 
eases. From  20  to  50  per  cent,  of  the  population  are  car- 
riers of  the  pneumococcus.  During  outbreaks  of  cerebro- 
spinal meningitis  the  number  of  carriers  may  be  from  ten  to 
thirty  times  as  numerous  as  the  number  of  cases.  Even  when 
diphtheria  is  not  prevalent,  i  per  cent,  of  the  population 
may  be  carrying  the  bacilli,  and  during  epidemics  the  num- 
ber may  be  several  times  higher.  Probably  25  per  cent,  of 
all  typhoid  fever  cases  excrete  bacilli  for  some  weeks  after 
convalescence,  and  it  is  estimated  that  from  i  in  500  to  i 
in  250  of  the  population  are  chronic  carriers.  They  are  prob- 
ably as  numerous  in  cholera  and  dysentery.     In  malaria 


156  SANITATION  FOR  MEDICAL  OFFICERS 

carriers  are  particularly  numerous,  but  there  is  no  evidence 
that  there  are  many  carriers  of  measles  or  smallpox. 

7.  Any  scheme  of  prevention  which  fails  to  take  into 
account  carriers  and  missed  cases,  is  doomed  to  partial  and 
perhaps  to  complete  failure. 

III.  Limitations  to  the  Value  of  Isolation. — i.  Isola- 
tion of  known  cases  will  be  of  little  preventive  value  if  the 
still  more  numerous  missed  cases  and  carriers  are  permitted 
to  be  at  large.  Isolation  has  been  a  failure  in  most  cities 
for  such  diseases  as  diphtheria,  measles,  and  scarlet  fever 
for  this  reason.  (It  is  probable  that  with  men  under  military 
control  and  with  an  efficient  sanitary  service  and  diagnostic 
laboratory  facilities,  better  results  may  be  secured  by  isola- 
tion in  the  army.) 

2.  The  danger  to  be  apprehended  from  a  single  infected 
person  is  much  less  than  has  been  supposed. 

3.  Isolation  is  of  far  less  value  than  was  beheved  a  few 
years  ago. 

4.  The  fewer  the  number  of  infected  persons  in  a  commu- 
nity or  institution  the  more  likely  is  isolation  to  be  successful. 
Isolation  in  an  extensive  outbreak  rarely  accomplishes 
much.  The  ejffectiveness  of  isolation  varies  inversely  as  to  the 
number  of  missed  cases  and  carriers. 

5.  Hospitalization  in  such  diseases  as  scarlet  fever  and 
diphtheria  cannot  be  expected  to  exterminate  them,  and 
many  patients  can  be  as  well  cared  for  in  their  homes. 

6.  In  diphtheria,  scarlet  fever,  and  measles  there  is  rarely 
and  only  in  certain  occupations,  any  necessity  for  interfering 
with  the  wage-earners  of  the  family. 

7.  The  isolation  of  school-children  should  be  more  strict 
than  that  of  adults,  for  less  hardship  results,  and  there  is 
more  danger  in  the  mingling  of  children  than  in  the  inter- 
course of  adults. 

IV.  Infection  by  Contact. — This  is  the  most  obvious 
mode  of  transmission  of  many  of  the  infectious  diseases. 


NOTES  ON  TRANSMISSIBLE  DISEASES  15'/ 

Venereal  diseases  are  all  conveyed  by  contact,  either  direct 
or  indirect.  Typhoid  is  frequently  a  contact  infection,  espe- 
cially among  soldiers,  and  the  same  is  undoubtedly  true  of 
cholera  and  dysentery.  Contact  infection  is  especially  dan- 
gerous because  of  carriers  and  missed  cases.  The  danger 
from  saUva  is  especially  great.  The  fingers  are  frequently 
brought  in  contact  with  the  mouth  and  nose,  and  if  infection 
is  present  it  is  conveyed  to  all  objects  and  people  subse- 
quently touched.  One  shakes  hands  with  a  man  having  a 
cold,  and  then  perhaps  Hcks  a  postage  stamp,  and  then  we 
wonder  from  whom  we  contracted  the  cold.  The  methods 
of  direct  or  indirect  contact  are  infinite,  and  most  infectious 
diseases  are  conveyed  in  this  way. 

V.  Intection  BY  FoMiTES. — I.  There  is  no  good  epidemio- 
logical evidence  that  any  diseases  except  those  due  to  spore- 
bearing  bacteria  are  to  any  great  extent  transmitted  by 
fomites. 

2.  Judging  from  our  experience  with  yellow  fever,  most  of 
the  alleged  evidence  of  infection  by  fomites  is  not  to  be  relied 
upon. 

3.  Even  if  all  the  alleged  fomites  infection  is  real,  only  a 
very  small  part  of  contagious  disease  is  traceable  to  this 
source. 

4.  The  theory  of  fomites  infection  was  an  a  priori  not  an 
a  posteriori  theory,  and  is  no  longer  demanded  to  explain 
the  facts. 

5.  Other  modes  of  transmission  account  for  the  spread  of 
disease  so  much  more  satisfactorily  that  there  seems  to  be 
really  little  opportunity  for  infection  by  fomites. 

6.  Laboratory  investigation  shows  that  fomites  infection 
with  spore-bearing  bacteria  is  common;  that  such  infection 
in  typhoid  fever,  tuberculosis,  diphtheria,  and  with  other 
resistant  organisms  doubtless  sometimes  takes  place;  that 
it  is  possible  in  cholera  and  plague,  while  such  infection  in 


158  SANITATION  FOR  MEDICAL  OFFICERS 

gonorrhea,  influenza,  meningitis^  and  pneumonia  must  be 
practically  impossible. 

7.  Fomites  infection  is  impossible  in  yellow  fever,  malaria, 
and  other  insect-borne  diseases.  Finally,  it  may  be  affirmed 
that  fomites  infection  is  of  very  much  less  importance  than 
was  formerly  believed.  (It  naturally  follows  that  terminal 
disinfection  is  of  very  much  less  importance  than  was  for- 
merly beUeved,  and  that  it  is  useless  in  diseases  that  cannot 
be  spread  by  fomites.) 

VI.  Infection  by  the  Air. — i.  The  theory  of  aerial  trans- 
mission of  disease  was  developed  as  the  most  reasonable 
way  of  explaining  the  method  of  transmission,  but  contact 
infection  with  carriers  and  missed  cases  affords  a  better 
explanation  of  the  phenomena,  and  the  best  medical  thought 
has  been  steadily  restricting  the  supposed  sphere  of  aerial 
transmission.  Only  a  few  authorities  now  assert  that  dis- 
ease is  carried  by  the  atmosphere  outside  of  dwellings,  and 
this  assertion  is  only  made  with  regard  to  smallpox. 

2.  Bacteriology  teaches  that  most  diseases  are  not  Ukely 
to  be  dust-borne,  and  they  are  spray-borne  only  for  two  or 
three  feet,  a  phenomenon  which  resembles  contact  infection 
more  than  aerial  infection  as  ordinarily  understood.  Tuber- 
culosis is  the  only  common  disease  that  is  likely  to  be 
air-borne. 

3.  There  is  considerable  evidence  that  scarlet  fever,  diph- 
theria, smallpox,  measles,  whooping-cough,  typhoid  fever, 
and  plague  are  not  easily  transmissible  through  the  air. 

4.  Scarlet  fever  and  diphfheria  can  be  cared  for  in  the  same 
ward  with  other  diseases  without  extension  if  surgical  clean- 
liness be  maintained,  and  infection  by  contact  avoided. 

DISINFECTION  AND  DISINFECTANTS.    * 

Terminal  Disinfection. — The  value  of  terminal  disin- 
fection has  been  greatly  overestimated  in  the  past  when  it 
was  believed  that  most  diseases  could  be  transmitted  by 


p 

NOTES  ON  TRANSMISSIBLE  DISEASES  159' 

fomites.  It  is  now  generally  recognized  that  most  disease? 
are  spread  by  people  rather  than  by  objects,  and  that  terminal 
disinfection  will  be  useless  in  such  diseases  as  measles,  whoop- 
ing-cough, influenza,  pneumonia,  cerebrospinal  meningitis, 
diphtheria,  t3^hus,  etc. 

In  the  case  of  diseases  of  unknown  etiology,  such  as  small- 
pox, terminal  disinfection  may  be  valuable,  and  is  very 
generally  employed  on  the  principle  of  taking  no  chances. 
In  the  military  service  and  elsewhere  formaldehyde  gas  is 
very  extensively  used  for  this  purpose.  For  generating  this 
gas,  I  pint  of  formaldehyde  solution  and  i  pound  of  potas- 
sium permanganate  and  J  pint  of  water  should  be  mixed  in 
a  deep  container  {e.  g.,  a  close  stool).  This  quantity  is  ade- 
quate for  looo  cubic  feet  of  air  space,  and  the  necessary 
articles  are  all  carried  on  the  supply  table. 

Disinfection  of  Bedding  and  Clothing. — Should  there 
be  no  fecal  or  other  stains,  such  articles  may  be  immersed 
in  boiUng  water.  Should  they  be  stained,  they  may  be  soaked 
in  solutions  of  phenol,  one  of  the  cresols,  or  formahn  of  5 
per  cent,  strength.  Such  treatment  is  usually  only  necessary 
after  the  intestinal  diseases,  such  as  typhoid,  cholera,  and 
dysentery.  Outer  clothing  may  be  disinfected  with  formal- 
dehyde gas  should  this  be  necessary.  The  destruction  of 
clothing  or  bedding  is  practically  never  necessary.  (See  Par. 
230,  M.  M.  D.,  1916.) 

Sputum. — In  pneumonia,  tuberculosis,  influenza,  and 
other  conditions  in  which  the  sputum  is  infectious  it  may  be 
received  in  spit  cups  partially  filled  with  disinfectant  and 
kept  covered  when  not  in  use;  5  per  cent,  phenol,  cresol,  or 
formalin  may  be  used.  Bichloride  solution  should  never  be 
used  to  disinfect  albuminous  matter. 

Feces. — The  bowel  discharges  in  typhoid,  dysentery, 
cholera,  intestinal  tuberculosis  and  other  infectious  intestinal 
diseases  should  be  received  in  vessels  containing  an  amount 
of  disinfectant  solution  somewhat  larger  than  the  probable 


160  SANITATION  FOR  MEDICAL  OFFICERS 

volume  of  the  excreta,  and  sufficient  to  entirely  cover  it  if 
solid.  Milk  of  lime  and  chlorinated  lime  are  efficient.  Phenol, 
cresols,  or  formaUn  may  be  used  in  5  per  cent,  solutions. 
Should  none  of  these  be  obtainable  the  stool  may  be  disin- 
fected after  deposition  by  filling  the  bed-pan  with  boiUng 
water.  In  any  case  the  stool  should  be  thoroughly  mixed 
with  the  disinfectant  and  allowed  to  stand  for  some  time. 
Pine  Oil. — Has  been  recommended  as  a  disinfectant. 
Heat  in  a  covered  enamel  pail,  1000  grams  of  pine  oil  with 
400  grams  of  pulverized  resin  until  dissolved.  Cool  to  80° 
C.  and  add  25  ounces  of  a  25  per  cent,  solution  of  sodium 
hydroxide  and  agitate  thoroughly  for  ten  minutes  with  a 
Dover  egg  beater.  Add  water  sufficient  to  bring  the  mix- 
ture up  to  its  original  weight  and  cool  by  placing  the  pail  in 
ice- water.  The  resin  used  is  strained  grade  E,  w^hich  formerly 
cost  2J  cents  a  pound.  The  pine  oil  formerly  cost  from  40 
to  50  cents  a  gallon,  so  that  the  total  cost  of  this  mixture 
was  about  50  cents  a  gallon.  It  is  understood  l:hat  since  the 
war  the  prices  of  these  articles  have  risen  so  that  it  is  no 
longer  cheaper  than  other  antiseptics;  at  the  same  time 
since  phenol  and  cresols  are  almost  prohibitive  in  price  the 
above  formula  may  be  useful. 


ANIMALS  CONCERNED  IN  DISEASE  TRANSMISSION. 

Human  Diseases  are  Carried: 
I.  By  the  Dog: 
Rabies. 

Foot-and-mouth  disease. 
Helminthiasis. 
Flukes. 

Tapeworms  (especially  Tenia  echinococcus). 
Infantile  splenomegaly  (from  dogs  through  fleas). 


NOTES  ON  TRANSMISSIBLE  DISEASES  161 

Human  Diseases  Are  Carried  (Continued) : 

2.  By  the  Cow: 

Tuberculosis. 

Actinomycosis. 

Anthrax. 

Cow-pox, 

Tetanus  (through  vaccine). 

Foot-and-mouth  disease. 

Septic  sore  throat   (streptococci  in  milk  of  cowa 

suffering  from  mastitis). 
Rabies  (rare). 
Tenia  saginata. 

3.  By  the  Horse: 

Glanders. 
Rabies  (rare). 
Tetanus. 
Sporotrichosis. 
Anaphylaxis. 

Serum  sickness,  acute  anaphylaxis  after  use  of 
antitoxins,  odor  of  horses. 

4.  By  Swine: 

Trichiniasis. 
Tenia  soHum. 
Tuberculosis  (rare). 

5.  By  Sheep: 
Anthrax. 

6.  By  Goats: 
Malta  fever. 

-    J.  By  the  Antelope: 

Sleeping  sickness   (the   antelopes   are   the  natural 
reservoir  of  the  T.  Gambiense). 
8.  By  the  Cat: 
Rabies. 
Cestodes. 
Trematodes, 
11 


162  SANITATION  FOR  MEDICAL  OFFICERS 

Human  Diseases  Are  Carried  (Continued) : 
g.  By  Rats: 

Bubonic  plague  (through  fleas). 
Trichiniasis  (through  hogs  to  man). 
Rat-bite  fever. 

10.  By  Ground  Squirrels: 

Bubonic  plague. 

11.  By  Birds: 

Psittacosis  (from  parrots). 

12.  By  Fish: 

Cestodes  (Bothriocephalus  latus). 

13.  By  Arthropods,  chiefly  Insects: 

Ticks  and  Mites: 

Rocky    Mountain    spotted    fever    (Dermacentor 
venustis  the  transmitter). 

African  relapsing  fever   (Ornithodorus   moubata 
the  transmitter  of  S.  duttoni). 

Japanese  Tstutsugamushi  fever  (A  mite,  Trom- 
bidium  is  the  transmitter). 
Mosquitoes: 

Yellow  fever. 

Malaria. 

Filariasis. 

Dengue. 
By  Fleas: 

Bubonic  plague. 

Infantile  splenomegaly. 
By  Lice: 

Typhus  fever  (P.  vestimenti  the  usual  transmitter). 

European  relapsing  fever  (Spirocheta  obermeieri). 
By  Bed-bugs: 

Kala  azar  (probably). 

European  relapsing  fever. 


1 


NOTES  ON  TRANSMISSIBLE  DISEASES  163 

Human  Diseases  Are  Carried  (Continued) : 

By  Flies: 
p.  Sandfly  fever  or  Pappataci  fever  (transmitted  by 

E|.  the  phlebotomus). 

E,  Sleeping  sickness  or  trypanosomiasis  (transmitted 

^  by  Glossina  palpalis) . 

Typhoid  and  other  infections  (by  Musca  domes- 
tica,  mechanically). 
By  Crustaceans: 

Guinea  worm  or  dracunculosis  transmitted  by  the 
Cyclops. 
By  Mollusks: 
Typhoid  fever  transmitted  by  oysters,  clams,  etc. 
Trematode  infections,  particularly  schistosomiasis, 
transmitted  by  snails. 

CEREBROSPINAL  MENINGITIS. 

This  disease  occurs  in  sporadic  and  epidemic  form,  usually 
in  the  winter  and  spring.  The  concentration  of  young  men 
in  barracks  is  a  special  factor  in  the  development  of  the  dis- 
ease, because  recruits  and  young  soldiers  have  always  been 
especially  susceptible,  and  many  epidemics  have  occurred 
among  troops. 

Etiology. — The  Diplococcus  intracellularis  or  Meningo- 
coccus. There  are  several  types  of  this  organism  which  are 
culturally  identical,  but  may  be  distinguished  by  their 
agglutination  reactions. 

Method  of  Transmission. — The  disease  is  not  highly  con- 
tagious and  is  not  transmitted  by  clothing  or  fomites,  since 
the  meningococcus  has  not  been  found  outside  the  human 
body  but  is  probably  spread  by  contact  with  cases  of  the 
disease  or  with  carriers  who  in  turn  have  been  in  contact  with 
a  case.  The  meningococcus  is  found  in  the  nasopharynx  of 
cases  of  the  disease  and  of  carriers,  and  the  carriers  prac- 
tically always  harbor  the  same  type  of  the  organism  as  that 


164  SANITATION  FOR  MEDICAL  OFFICERS 

found  in  the  case  with  which  they  have  been  in  contact.  It 
is  believed  that  the  organism  gains  entrance  to  the  system 
through  the  mucous  membrane  of  the  nasopharynx,  and  that 
the  infection  is  spread  through  contact  transference  of  the 
discharges  and  secretions  from  the  mouth  and  nose.  The 
carriers  of  the  disease  may  be  many  times  more  numerous 
than  the  recognized  cases. 

Incubation  Period. — This  is  not  known  with  certainty, 
owing  to  the  fact  that  it  is  usually  impossible  to  tell  when  the 
infection  was  acquired. 

Sanitary  Measures. — If  prompt  measures  are  taken  as 
soon  as  a.  case  appears  to  identify  and  isolate  contacts,  there 
may  be  no  further  spread  of  the  disease.  If  such  measures 
are  deferred  until  a  number  of  cases  have  occurred,  or  should 
the  first  steps  prove  ineffective,  the  situation  becomes  much 
more  difficidt  because  of  the  very  large  number  of  contacts. 
It  is  impracticable  to  isolate  so  many  men,  most  of  whom 
are  not  infected,  so  that  if  anything  is  to  be  done  an  examina- 
tion of  the  contacts  must  be  made  to  detect  carriers.  This 
work  can,  only  be  done  by  a  diagnostic  laboratory  working 
on  the  spot.  Swabs  and  throat  cultures  of  the  meningo- 
coccus cannot  be  mailed  to  a  department  laboratory  because 
the  organism  will  not  usually  live  under  such  circumstances. 
In  view  of  the  above  facts,  when  a  case  appears  in  camp  the 
following  measures  should  be  taken: 

I.  Prompt  Diagnosis. — ^Lumbar  puncture  should  be  made 
early  in  a  suspected  case.  The  fluid  withdrawn  is  generally 
purulent  in  positive  cases,  but  in  any  case  stained  smears 
should  be  examined.  Lofiier's  methylene  blue  and  Gram's 
stain  may  be  used.  Should  there  be  numerous  pus  cells  con- 
taining biscuit-shaped  Gram-negative  diplococci  which  closely 
simulate  the  appearance  of  the  gonococcus  a  positive  diagnosis 
may  be  made.  The  pneumococcus  is  not  infrequently  the 
cause  of  cases  of  meningitis,  but  these  cases  are  sporadic, 
not  epidemic.    The  pneumococcus  may  be  distinguished  by 


NOTES  ON  TRANSMISSIBLE  DISEASES  165 

the  fact  that  it  is  Gram-positive  and  is  lanceolate  rather 
than  biscuit-shaped,  and  is  not  found  so  frequently  in  the 
leukocytes.  Camp  hospitals  should  be  equipped  to  make 
these  simple  stains,  and  may  also,  if  practicable,  make  cultures 
from  the  fluid  on  blood  serum  or  blood  agar.  Early  diagnosis 
is  important,  as  it  enables  steps  to  be  taken  promptly  to 
isolate  contacts  and  possible  carriers. 

2.  Isolation  of  Contacts. — ^AU  the  men  in  the  same  tent  or 
room  may  be  considered  to  be  contacts,  together  with  any 
other  men  with  whom  the  patient  has  been  intimate.  When 
a  case  has  occurred  it  is  quite  usual  to  find  that  several  men 
in  the  same  squad  room  are  infected  and  will  either  develop 
the  disease  or  become  healthy  carriers.  These  men  should 
be  placed  in  a  detention  ward  and  watched  until  all  danger 
of  an  epidemic  is  past  or  until  sw^abs  have  shown  the  absence 
of  meningococci  in  the  nasopharynx. 

3.  Isolate  the  patient  in  a  separate  room  in  the  hospital 
and  disinfect  the  secretions  from  the  mouth  and  nose.  A 
carboUc  mouth  wash  and  an  antiseptic  spray  for  the  nose 
may  be  used.  Physicians  and  attendants  should  take 
measures  to  avoid  transference  of  infection  to  their  own 
throats  and  noses,  including  washing  the  hands  immediately 
after  attending  to  the  patient.  The  nasal  secretions  of  the 
patient  may  be  received  into  pieces  of  gauze,  which  should 
be  promptly  burned. 

II.  Should  secondary  cases  appear,  or  should  circumstances 
be  such  that  an  epidemic  is  feared,  request  should  be  made 
to  the  chief  surgeon  by  telegraph  for  a  field  laboratory.  With 
laboratory  work  performed  on  the  ground  the  following 
steps  may  be  taken : 

'      I.  Cultures  frgm  both  spinal  fluid  and  nasophar3.^nx  of 
cases  to  determine  the  t>"pe  of  organism.- 
!      2.  Examination  of  the  nasopharynx  of  all  x:ontacts  to  detect 
I  carriers.    This  may  be  done  by  means  of  sw^abs,  which  should 
I  be  plated  at  once  as  soon  as  the  swab  is  taken,  and  the  single 


166  SANITATION  FOR  MEDICAL  OFFICERS 

colonies  that  develop  can  be  tested  in  about  twentv-four 
hours  with  immune  serum  to  determine  not  only  whether  the 
meningococcus  is  present  but  also  to  determine  the  type.  If 
the  type  of  organism  found  in  the  contacts  is  the  same  as  that 
found  in  the  patient,  no  other  source  of  infection  need  be 
suspected.  However,  should  types  be  found  other  than  those 
found  in  the  patient,  other  carriers  must  be  present  and 
should  be  searched  for.  This  may  be  done  by  examining  the 
contacts  of  the  contacts.  This  necessarily  entails  a  large 
amount  of  work,  as  during  an  epidemic  lo  per  cent,  of  the 
men  may  be  carriers. 

3.  All  carriers  to  be  isolated  until  negative  swabs  can  be 
obtained.    All  men  not  carriers  to  be  released  at  once. 

4.  Treatment  of  carriers  to  remove  infective  organisms.  A 
carbolic  mouth  wash  may  be  used  with  antiseptic  sprays. 
Various  nasal  sprays  have  been  used,  including  Dobell's 
solution,  iodin  and  menthol,  chlorin  water  (potassium 
chlorate  10  grains,  strong  HCl  2  drops,  water  to  i  ounce), 
and  chloramin  solution  i  to  2  per  cent.  Chloramin  appeared 
to  be  the  most  useful  form  of  spray  in  one  set  of  observations, 
but  it  cannot  be  said  that  any  of  them  was  especially 
efficacious. 

Inhalations. — Kuster  {Deutsch.  med.  Wchnschr.,  September 
I,  191 5)  states  that  early  in  191 5  a  few  cases  of  cerebrospinal 
meningitis  occurred  among  the  troops  at  Cologne,  and  an 
investigation  showed  that  from  50  to  60  per  cent,  of  the  men 
were  carriers.  As  there  was  little  prospect  of  sterilizing  these 
men  by  individual  treatment,  they  were  treated  in  an  inhala-. 
torium,  100  men  at  a  time.  The  disinfectant  used  contained 
a  hyi:)Ochlorite  which  gave  off  chlorine  on  contact  with  acids. ' 
Meningococci  exposed  to  the  action  of  this  disinfectant  were' 
killed  within  an  hour.  After  three  visits  to  the  inhalatoriui 
on  three  successive  days  the  carriers  were  no  longer  found  t( 
harbor  meningococci.  Although  the  inhalatorium  smell 
strongly  of  chlorin,  no  ill  effects  were  observed.    It  was  also 

1 


NOTES  ON  TRANSMISSIBLE  DISEASES  167 

i 

claimed  that  the  same  results  were  obtained  mth  diphtheria 
carriers.  The  obser\'ation  is  given  for  what  it  may  be  worth, 
and  as  other  processes  have  been  disappointing  it  may  be 
worthy  of  a  trial. 

III.  Genereal  Measures. — Take  steps  to  prevent  over- 
crowding, and  to  educate  soldiers  to  avoid  contact  infection. 
(See  note  on  Overcrow^ding  and  Contact  Infection.) 

CHOLERA. 

Etiology. — Spirillum  cholerae  asiaticae. 

Method  of  Transmission. — The  organisms  from  the  excreta 
or  vomitus  of  a  previous  case  must  be  swallowed.  Cholera 
may  be  transmitted  by  means  of  infected  water  supplies, 
by  infected  food,  or  by  direct  contact  with  a  case  of  the 
disease  or  with  carriers.  As  in  the  case  of  typhoid,  flies  may 
carry  the  organism  from  the  excreta  to  the  food.  In  later 
years  carriers  have  assumed  great  importance.  In  Germany, 
in  1905,  of  those  persons  placed  under  observation,  from 
5  to  12  per  cent,  were  carriers;  in  Manila,  in  1908,  about 
7  per  cent,  were  found.  Convalescents  or  carriers  have  been 
demonstrated  to  harbor  the  spirillum  in  the  stools  for  from 
ten  to  sixty-nine  days.  Gaflky  reported  one  case  who  was  a 
carrier  for  six  months,  and  another  observer  reported  that  in 
two  cases  spirilli  reappeared  in  the  stools  after  a  negative 
period  of  twenty  days  and  one  month  respectively.  These 
long-time  carriers  make  a  farce  of  the  usual  five-day 
quarantine  without  stool  examination. 

Incubation  Period. — Usually  two  to  five  days.    (Osier.) 

Prophylaxis  and  Control. — I.  General  Measures. — i. 
The  Provision  of  Pure  Food  and  Drink. — The  water  supply 
must  be  above  suspicion  or  must  be  purified.  Milk  should  be 
pasteurized  or  canned.  During  an  epidemic  food  should  be 
served  hot  on  hot  plates,  and  no  raw  vegetables  should  be 
eaten,  particularly  in  countries  where  human  excreta  is  used 
for  fertilizer.    The  skins  of  fruits  that  are  to  be  eaten  raw 


168  SANITATION  FOR  MEDICAL  OFFICERS 

should  be  washed  off  with  a  disinfectant  solution  (phenol  i 
to  2  per  cent.). 

2.  A  Sanitary  and  Satisfactory  Disposition  of  all  Excreta. — 
Access  of  flies  to  excreta  must  be  absolutely  prevented,  and 
excreta  must  be  so  disposed  of  that  contamination  of  water 
is  impossible. 

3.  Prevention  of  Contact  Infection  from  Soiled  Hands. — ^All 
persons  in  the  military  service  should  be  compelled  to  wash 
the  hands  after  leaving  the  rear,  and  all  persons  not  in  the 
military  service  should  be  educated  to  do  the  same.  Cholera 
in  Bilibid  prison  was  probably  caused  by  carriers,  and  was 
suppressed  by  an  order  compelling  disinfection  of  the  hands 
under  guard  after  leaving  the  latrines  and  before  eating. 

4.  Prevention  of  Fly  Transmission. — Measures  must  be 
taken  to  eradicate  flies  (see  Flies),  to  screen  kitchens  and 
mess  halls,  and  to  prevent  all  access  of  flies  to  either  excreta 
or  food. 

II.  Specific  Measures. — i.  Measures  to  Secure  Prompt 
Notification  of  All  New  Cases. — When  dealing  with  native 
races  it  may  be  assumed  that  notification  cannot  be  enforced. 
Here  a  medical  certificate  as  to  the  cause  of  death  must  be 
required  before  a  permit  for  burial  is  issued,  and  all  suspicious 
cases  must  be  subjected  to  postmortem  examination. 

2.  Prompt  Isolation  of  Cases  or  Suspected  Cases  in  Hospital. 
— Cholera  wards  or  rooms  to  be  fly-proof  and  measures  to 
be  taken  to  disinfect  all  stools  and  vomitus  and  to  prevent 
infection  of  nurses  and  attendants.  Nurses  should  disinfect 
the  hands  after  handling  patients,  and  cultivate  the  habit 
of  keeping  the  fingers  away  from  the  mouth. 

3.  AH  contacts  to  be  isolated  in  small  groups  in  a  detention 
camp  for  five  days.  If  they  do  not  develop  cholera  a  stool 
examination  must  be  made  to  detect  carriers.  All  not  found 
to  be  carriers  may  be  released  at  the  end  of  five  days. 

4.  All  convalescent  cases  of  the  disease  and  carriers  to  be 


NOTES  ON  TRANSMISSIBLE  DISEASES  169 

detained   until   three   successive   negative   stool   reports  at 
intervals  of  a  week  apart  can  be  obtained. 

III.  Vaccination. — Should  cholera  appear  among  troops 
they  should  all  be  given  a  prophylactic  dose  of  cholera  vaccine 
which  may  be  prepared  in  the  same  manner  as  typhoid  vac- 
cine. The  evidence  indicates  that  this  vaccine  affords  a  high 
degree  of  protection  for  several  months  at  least. 

IV.  Quarantine. — Quarantine  regulations  of  the  United 
States  state  that  for  the  purpose  of  these  regulations  five  days 
shall  be  considered  as  the  incubation  period  of  cholera. 

All  ships  arriving  under  five  days  from  cholera-infected 
ports  or  that  have  had  cases  of  cholera  on  board  must  be 
detained  for  this  period.  Carefully  isolate  those  especially 
suspected  (contacts),  and  segregate  the  remainder  of  the 
passengers  in  small  groups.  Stool  examinations  should  be 
made  in  all  cases  to  detect  carriers. 

Method  of  Stool  Examination. — By  the  following  method 
one  person  may  examine  from  loo  to  150  stools  per  day,  a 
report  being  obtainable,  as  a  rule,  in  twenty-four  hours.  Inocu- 
late enriching  peptone  solution  as  soon  as  the  stool  is  secured, 
if  possible  in  the  morning.  Make  agar  plates  at  night  and 
examine  the  colonies  the  following  morning.  A  macroscopic 
agglutination  test  is  performed  on  all  suspicious  colonies  on  a 
glass  slide  in  the  following  manner:  Place  a  loopful  of  physio- 
logical salt  solution  on  the.shde  and  emulsify  the  suspicious 
colony  in  it.  Add  one  loopful  of  a  strong  cholera-immune 
serum  (agglutination  i  to  5000  or  higher)  in  a  dilution  of  i  to 
100.  This  makes  the  dilution  on  the  slide  i  to  200.  In  this 
dilution  cholera  vibrios  are  immediately  agglutinated.  The 
agglutinated  colonies  may  be  identified  further  by  cultural 
methods  later,  but  for  sanitary  purposes  all  cases  in  which 
vibrios  are  found  giving  a  positive  agglutination  should  be 
detained  as  carriers.    All  negative  cases  may  be  released. 


170  SANITATION  FOR  MEDICAL  OFFICERS 

COLDS. 

The  common  cold  is  the  cause  of  much  suffering  and  dis- 
ability and  in  addition  is  a  predisposing  cause  of  many  other 
infectious  diseases  including  tuberculosis  and  pneumonia. 
It  probably  causes  more  loss  of  efficiency  than  any  of  the 
acute  infectious  diseases.  For  these  reasons  an  endeavor 
should  be  made  to  limit  the  spread  of  this  disease  as  much  as 
possible. 

Etiology. — Many  organisms  have  been  incriminated  in- 
cluding streptococci,  the  pneumococcus,  micrococcus  catar- 
rhalis,  and  the  B.  rhinitis  of  TunnicUff.  Recent  work  by 
Captain  George  B.  Foster  indicates  that  these  organisms  are 
secondary  invaders,  and  that  the  real  cause  is  a  filtrable  virus. 

Method  of  Transmission. — ^The  common  cold  is  highly 
infectious,  and  when  one  individual  in  a  house  or  tent  devel- 
ops the  disease,  secondary  cases  are  frequent.  The  virus  is 
present  in  the  nasal  secretion  and  probably  in  the  buccal 
secretions,  and  is  conveyed  to  the  nose  or  throat  of  healthy 
individuals  by  means  of  the  droplets  expelled  during  cough- 
ing and  sneezing,  and  also  by  direct  contact.  The  fingers 
of  the  patient  are  probably  constantly  infected.  Exposure 
to  cold  and  sudden  changes  of  temperature  are  undoubtedly 
predisposing  causes. 

Period  of  Incubation. — In  experimental  cases  this 
ranged  from  six  to  thirty  hours. . 

Prophylaxis. — I.  General  Measures. — i.  Prevention  of 
overcrowding  and  measures  to  avoid  contact  infection. 
Education  of  the  men  by  means  of  posters  or  other  methods, 
so  that  those  infected  will  be  careful  to  protect  others  from 
the  infectious  droplets  by  the  proper  use  of  handkerchiefs. 
If  handkerchiefs  are  not  available,  pieces  of  gauze  may  be 
used  and  subsequently  burned. 

2.  Protection  of  the  men  from  extremes  and  great  varia- 
tions in  temperature  as  far  as  possible.  This  entails  the  issue 
of  clothing  adapted  to  the  climatic  conditions,  and  some 


NOTES  ON   TRANSMISSIBLE   DISEASES  171 

oversight  on  the  part  of  surgeons  and  company  officers  to 
see  that  the  proper  clothing  is  actually  worn.  If  such  cloth- 
ing is  not  available,  mention  of  the  fact  should  be  made  in 
the  regular  or  a  special  sanitary  report. 

II.  Specific  Measures. — i.  When  possible  isolate  by  treat- 
ing the  man  in  bed  in  the  hospital.  This  will  not  only  be 
better  for  him,  but  will  prevent  the  general  dissemination  of 
the  condition  throughout  the  command. 

2.  When  this  is  not  possible,  at  least  begin  treatment 
promptly.  Local  treatment  of  the  nose  with  thorough 
douching  and  cleansing  does  not  cure,  but  it  does  relieve 
the  symptoms  so  that  sneezing  and  coughing  will  be  much 
reduced.  This  reduces  the  danger  of  disseminating  the 
disease  very  materially. 

DENGUE. 

!  Dengue  is  practically  never  fatal,  but  it  generally  occurs  in 
j  widespread  epidemics,  and  as  the  disease  incapacitates  a  man 
completely  for  from  one  to  two  weeks,  it  is  frequently  the 
cause  of  much  loss  of  efficiency.  Epidemics  are  frequent 
among  troops  in  the  Phihppines,  and  the  disease  is  common 
in  Texas,  Mexico,  Cuba,  Puerto  Rico,  Panama  and  other 
countries  where  our  troops  may  serve. 

Etiology. — A  filterable  virus  at  present  unknown. 
Method  of  Transmission. — The  blood  of  the  patient  is 
infectious,  and  the  disease  is  undoubtedly  transmitted  by 
the  bites  of  infected  mosquitoes.  The  experiments  of  Ash- 
burn  and  Craig  indicated  Culex  fatigans  as  the  transmitter, 
while  experiments  by  English  observers  have  incriminated 
Stegomyia  fasciata.  Both  of  these  mosquitoes  must  there- 
fore be  suspected,  although  it  is  probable  that  only  one  of 
them  is  the  actual  transmitter. 

Incubation  Period. — In  experimental  cases  produced  by  the 
bite  of  infected  stegomyia,  the  incubation  period  was  from 
six  to  nine  and  one-half  days.  (See  Journal  of  Hygiene,  1918, 
xvi,  317.) 


172  SANITATION  FOR  MEDICAL  OFFICERS 

Prophylaxis. — (See  Mosquitoes.) 

1.  Screen  all  patients  to  prevent  mosquitoes  from  becom- 
ing infected. 

2.  A  campaign  against  mosquitoes. 

3.  The  use  of  screening,  mosquito  bars,  and  other  measures 
to  prevent  healthy  individuals  from  being  bitten. 

DIPHTHERIA. 

Etiology. — B.  diphtheriae  (Klebs-Loeffler  bacillus). 

Method  of  Transmission. — The  organism  may  rarely  be 
present  in  milk,  but  aside  from  this  has  no  independent 
existence  in  nature.  Infection  must  be  received  from  some 
person  who  carries  the  bacilli  in  the  throat  or  nose,  and  who 
may  be  either  a  clinical  case  of  the  disease  or  a  carrier.  As 
most  of  the  marked  cases  of  diphtheria  are  isolated,  the 
spread  of  diphtheria  is  due  almost  exclusively  to  mild  missed 
cases  of  the  disease,  and  to  carriers. 

Susceptible  Age. — Schick  tests  have  indicated  that  80  per 
cent,  of  the  newborn  contain  sufficient  antitoxin  to  protect, 
but  that  this  number  rapidly  decreases,  so  that  the  period 
of  greatest  susceptibility  is  from  the  end  of  the  first  year  to 
the  end  of  the  fifth  year,  during  which  time  from  50  to  60 
per  cent,  of  children  contain  sufficient  antitoxin  in  the  blood 
to  be  immune.  After  this  period  the  percentage  gradually 
rises  until  among  adults  90  per  cent,  are  immune.  From 
this  it  will  be  seen  that  while  diphtheria  may  occur  among 
soldiers  it  is  not  apt  to  become  epidemic.  The  measures 
outlined  below  will  generally  eradicate  the  disease,  and  will 
at  least  limit  its  spread. 

Incubation  Period. — Two  to  seven  days,  oftenest  two. 
(Osier.) 

Control. — To  be  successful,  sanitary  work  must  be  car- 
ried out  with  the  close  cooperation  of  a  diagnostic  laboratory. 
The  diagnosis  of  the  disease  is  based  upon  the  finding  of 


^  NOTES  ON  TRANSMISSIBLE  DISEASES  173 

bacilli  in  the  throat  or  nose  which  are  morphologically  diph- 
theria. When  a  case  of  diphtheria  occurs  in  an  organization 
the  following  steps  may  1  e  taken: 

1.  Take  a  nose  and  throat  culture  on  blood  serum  from 
each  man  in  the  organization.  This  is  to  detect  developing 
cases  and  carriers. 

2.  Perform  the  Schick  test  on  all  men  of  the  organization. 
This  is  to  determine  which  men  are  susceptible  to  diphtheria. 

3.  When  the  report  from  the  laboratory  is  received,  isolate 
all  men  w^hose  cultures  show  bacilli  that  are  morphologically 
diphtheria. 

'  4.  Give  a  prophylactic  dose  of  antitoxin  (1000  units)  to 
those  who  have  been  in  contact  with  a  recognized  case  of  the 
disease,  and  who  have  a  positive  Schick  test. 

Generally  speaking,  30  to  80  per  cent,  of  cultures  of  bacilli 
from  carriers  who  have  not  had  diphtheria  and  have  not 
been  exposed  to  a  case  are  non-\drulent.  On  the  other  hand, 
bacilli  from  persons  who  have  had  diphtheria,  or  have  been 
intimately  exposed  to  the  disease,  are  virulent  in  from  61  to 
100  per  cent,  of  the  cases.  In  the  management  of  such  car- 
riers a  virulence  test  becomes  necessary,  as  it  is  useless  and 
very  troublesome  to  isolate  men  who  harbor  avirulent  bacilli. 
The  following  test  is  recommended. 

■  Virulence  Test. — Pure  cultures  of  the  organism  are  grown 
for  twenty-fom:  hours  on  slants  of  Loeffler's  blood  serum  in 
usual  sized  tubes;  10  c.c.  sterile  salt  solution  is  used  to  wash 
off  each  tube  and  an  even  emulsion  secured;  4  c.c.  of  this 
emulsion  is  injected  subcutaneously  in  the  median  abdom- 
inal line  of  a  guinea-pig  of  250  to  300  grams  weight.  Watch 
carefully  for  four  days  for  evidences  of  local  edema  and 
general  intoxication.  If  the  culture  has  no  effect  at  all  on 
the  guinea-pig,  it  is  avirulent,  and  cannot  produce  diphtheria. 

Rules  for  the  Management  of  Carriers. — i.  Carriers  having 
avirulent  organisms  as  shown  by  a  proper  virulence  test  on 
guinea-pigs  may  be. released  fr€>^m  isolation. 


174  SANITATION  FOR  MEDICAL  OFFICERS 

2.  Should  the  virulence  test  be  impracticable  the  carrier 
may  be  released  should  the  Schick  test  be  positive.  A  posi- 
tive tept  means  that  the  patient  is  susceptible  to  diphtheria, 
and  as  he  has  not  diphtheria,  the  deduction  is  drawn  that 
the  organisms  in  his  throat  are  avirulent. 

3.  All  carriers  having  virulent  organisms  and  all  patients 
recovering  from  diphtheria  must  be  isolated  in  hospital  until 
at  least  three  successive  negative  cultures  from  both  nose 
and  throat  can  be  secured.  Cultures  should  be  taken  every 
other  day. 

Comment. — The  rigid  isolation  of  all  diphtheria  carriers  in 
civil  life  is  probably  impracticable  nor  is  it  necessary.  Isola- 
tion has  generally  failed  to  control  the  disease  in  cities 
because  it  is  impossible  to  control  all  the  carriers,  and  it  does 
no  good  to  isolate  a  small  percentage  of  the  carriers  while 
allowing  the  others  to  go  free.  Moreover,  a  carrier  would 
be  of  little  danger  to  the  community  if  he  avoided  close 
contact  and  always  coughed  or  sneezed  into  a  handkerchief 
instead  of  into  the  surrounding  atmosphere.  However,  con- 
ditions are  different  in  the  military  service.  When  men  are 
crowded  in  tents  or  barracks,  or  perhaps  sleeping  side  by  side, 
close  contact  cannot  be  avoided.  Moreover,  with  men  under 
military  discipline  all  the  carriers  can  be  isolated,  so  that 
under  these  circumstances  isolation  is  more  necessary  than 
is  the  case  in  civil  hfe,  and  the  chances  that  it  will  be  made 
effective  are  much  better. 

Treatment  of  Carriers. — There  is  no  satisfactory  method  of 
treating  carriers  to  remove  the  diphtheria  bacilli  from  the 
nose  and  throat.  Kaolin,  yeast,  and  staphylococcus  sprays 
have  all  been  tried  and  found  wanting.  By  the  use  of  these 
methods,  negative  cultures  may  be  secured  while  the  bacilli 
are  still  present,  the  latter  being  merely  covered  up.  Paint- 
ing the  throat  with  silver  nitrate  solutions  is  of  dubious  value. 
Probably  a  simple  antiseptic  nasal  spray  and  gargle  will 
remove  the  offending  organisms  as  rapidly  as  any  other  j 
method.  | 


\  NOTES  ON  TRANSMISSIBLE  DISEASES  175 

Duration  of  Passive  Immunity. — The  duration  of  immunity 
following  the  prophylactic  injections  of  antitoxin  varies 
between  twenty-one  to  twenty-five  days,  as  shown  by  the 
Schick  test.  In  io8  children  studied  who  received  1250 
units  of  antitoxin,  it  was  determined  that  this  amount  con- 
ferred efficient  immunity  for  ten  days;  but  that  after  this 
interval  the  antitoxin  rapidly  disappeared,  so  that  after  four 
to  six  weeks  the  immunity  had  entirely  disappeared. 

The  Schick  Test. — A  fresh  solution  of  diphtheria  toxin  is 
prepared  of  such  strength  that  0.2  c.c.  represents  -^  of 
the  minimum  lethal  dose  of  toxin  for  a  250-gram  guinea-pig. 
This  amount  is  injected  with  a  good  syringe  and  a  fine  needle 
intracutaneously  on  the  flexor  surface  of  the  forearm.  A 
properly  made  injection  is  recognized  by  a  distinct  wheal- 
like  elevation.  The  result  of  the  test  should  be  read  at  the 
end  of  twenty-four,  forty-eight,  seventy-two  and  ninety-six 
hours. 

The  reaction  that  appears  at  the  site  of  injection  may  be 
either  positive,  negative,  pseudo,  or  combined  positive  and 
pseudo. 

The  positive  reaction  represents  the  action  of  an  irritant 
toxin  upon  cells  that  are  not  protected  by  antitoxin  and 
indicates  an  absence  of  immunity  to  diphtheria.  A  trace  of 
redness  appears  slowly  at  the  site  of  injection  in  from  twelve 
to  twenty-four  hours,  and  is  usually  a  distinct  reaction  in 
the  course  of  twenty-four  to  forty-eight  hours.  The  reac- 
tion reaches  its  height  on  the  third  or  fourth  day  and  gradu- 
ally disappears,  leaving  a  definitely  circumscribed  scaling 
area  of  brownish  pigmentation  which  persists  for  three  to 
six  weeks.  At  its  height  the  positive  reaction  consists  of  a 
circumscribed  area  of  redness  and  sUght  infiltration  which 
measures  from  i  to  2  cm.,  in  diameter. 

The  Negative  Reaction. — The  skin  at  the  site  of  injection 
remains  normal.  The  negative  reaction  definitely  indicates 
an  immunity  to  diphtheria  if  the  test  toxin  is  of  full  strength 


176  SANITATION  FOR  MEDICAL  OFFICERS 


\ 


and  the  injection  has  been  properly  made.  A  negative  reac- 
tion obtained  after  the  age  of  three  years  indicates  an  immu- 
nity that  is  probably  permanent.  Of  looo  carefully  observed 
individuals  no  one  developed  clinical  diphtheria,  even  though 
they  were  exposed  to  the  disease,  and  some  were  carriers  of 
virulent  diphtheria  bacilli. 

The  pseudoreaction  represents  a  local  anaphylactic 
response  of  the  cells  to  a  protein  substance.  Like  other 
anaphylactic  skin  phenomena  the  reaction  is  of  an  urticarial 
nature,  appears  early,  within  six  to  eighteen  hours,  reaches 
its  height  in  thirty-six  to  forty-eight  hours,  and  disappears 
on  the  third  or  fourth  day,  leaving  a  poorly  defined  small 
area  of  brownish  pigmentation  and  generally  no  scaling.  At 
its  height  it  shows  varying  degrees  of  infiltration,  and  appears 
as  a  small  central  area  of  dusky  redness  with  a  secondary 
areola,  which  gradually  fades  off  into  the  surrounding  skin. 
The  reaction  may  also  have  a  rather  uniform  red  appearance 
and  be  two  or  three  times  the  size  of  a  true  reaction.  A  con- 
trol test,  made  by  injecting  toxin  heated  to  75°  C.  for  five 
minutes,  gives  a  similar  reaction  which  passes  through  the 
same  clinical  course.  Individuals  who  give  a  pseudoreaction 
only  have  antitoxin  and  are  immune  to  diphtheria.  The 
false  reaction  is  seen  in  relatively  few  of  the  older  children, 
but  in  a  much  larger  number  of  adults,  in  whom  it  is  of 
importance  to  recognize  and  control  it  both  by  the  injection 
of  heated  toxin  and  by  observing  the  clinical  course  of  the 
reaction. 

The  toxin  for  the  performance  of  the  Schick  reaction  may 
be  obtained  through  the  Department  Laboratories. 

AMEBIC  DYSENTERY. 

>   Etiology. — Endameba   histolytica.     The   cysts   of   this 
organism  are  the  infecting  agent,  the  motile  forms  being 
destroyed  by  external  agencies  and  the  gastric  juice. 
Method  of  Transmission. — The  cysts  reach  the  intestine  of 


NOTES  ON  TRANSMISSIBLE  DISEASES  177 

I  man  by  ingestion  of  material  containing  cysts,  usually  con- 
taminated food  or  drink.     Contamination  may  occur  by 
direct  infection  from  soiled  fingers  (carriers),  by  flies  that 
'  have  been  in  contact  with  the  excreta  of  infected  individuals, 
through  the  improper  disposal  of  sewage  which  gains  access 
'  to  food  or  drink,  and  by  the  use  of  human  excrement  as  fer- 
I  tihzer,  and  by  dust  blowing  about,  and  which  may  contain 
I  cysts  from  dried  and  pulverized  feces.     This  latter  method 
!  is  not  important. 

'      Life  of  Cysts  Outside  the  Body. — Cysts  remain  unchanged  in 

I  water  for  a  period  of  at  least  twenty-five  days.     In  solid 

I  stools  they  remain  unchanged  for  a  month  in  portions  that 

retain  some  moisture.    When  exposed  to  sunlight  the  cysts 

dry  so  that  transmission  through  dust  is  exceptional.    Cysts 

may  be  found  in  an  unchanged  condition  in  the  intestine  and 

I  excreta  of  flies  as  long  as  eighteen  hours  after  these  insects 

I  have  fed  upon  material  containing  them. 

i      Carriers. — Many,  perhaps  the  majority,  of  patients  who 

'  have  had  amebic  dysentery  continue  to  pass  cysts  in  the 

i  stools  after  a  cHnical  cure  by  emetine  or  other  treatment. 

In  addition  to  this,  some  persons  may  pass  cysts  in  the 

stools,  although  they  have  not  had  clinical  dysentery.    Car- 

i  riers  of  this  infection  must  therefore  be  fairly  numerous. 

The  length  of  time  a  person  may  be  a  carrier  is  not  known, 

but  it  is  known  that  a  patient  may  continue  to  pass  the 

cysts  for  at  least  a  year.    It  is  probable  that  the  main  sources 

of  this  infection  among  soldiers  are  carriers  and  flies. 

Period  of  Incubation. — Walker  fed  20  men  material  con- 
taining cysts  of  E.  histolytica;  18  became  parasitized,  the 
average  time  of  appearance  of  endamebae  in  the  stools  being 
six  days.  Of  these  cases  4  developed  typical  amebic  dysen- 
tery, I  after  twenty  days,  i  after  fifty-seven  days,  i  after 
eighty-seven  days,  and  i  after  ninety-five  days,  the  average 
being  sixty-five  days.  Craig  analyzed  156  cases  on  the 
Mexican  border  and  found  that  35  per  cent,  developed  the 
12 


178  SANITATION  FOR  MEDICAL  OFFICERS 

disease  within  one  month  after  arrival,  65  per  cent,  within 
two  months  and  90  per  cent,  within  thiee  months. 

Prophylaxis. — I.  Carriers. — i.  When  a  case  of  this  dis- 
ease is  discovered  a  microscopic  examination  of  the  stools 
of  all  soldiers  who  are  concerned  with  the  preparation  of 
food  or  drink  should  be  made  at  once.  If  possible  this 
examination  may  include  all  members  of  the  organization. 
A  field  laboratory  may  be  sent  to  assist  in  diagnosis  and 
sanitary  control  of  this  disease. 

2.  If  carriers  are  detected,  they  should  be  admitted  to 
hospital  and  treated.  Treatment  with  emetine  bismuth 
iodide  is  said  to  remove  cysts  from  carriers.  According  to 
Lillie  and  Shepheard  {Jour.  Royal  Army  Med.  Corps,  191 7, 
xxix,  712),  95  per  cent,  of  amebic  carriers  are  cured  by  the 
administration  of  emetine  bismuth  iodide  in  daily  doses  of 
3  grains  until  at  least  36  grains  have  been  given.  Ordinary 
emetine  treatment  is  apt  to  be  unsuccessful.  Walker  and 
Emrich  in  a  recent  article  (Jour.  Am.  Med.  Assn.,  191 7,  p. 
1456)  recommend  oil  of  chenopodium.^  If  the  carrier  cannot 
be  cured,  he  should  be  discharged. 

3.  Elimination  of  carriers  b>  thorough  treatment  of  exist- 
ing cases  controlled  by  microscopic  examination  prior  to 
discharge  from  hospital.  No  case  to  be  returned  to  duty 
who  is  a  carrier. 

II.  General  Measures. — i.  Thorough  and  rapid  disposal 
of  all  feces.  Whatever  method  be  adopted,  it  must  be  so 
managed  that  the  water  supply  cannot  become  contami- 
nated, and  that  flies  cannot  gain  entrance  to  the  feces  in  the 
latrine.  All  members  of  the  command  to  wash  their  hands 
after  leaving  the  latrine. 

2.  Fly  screening  and  dertruction  of  flies.     (See  Flies.) 

3.  Provision  of  a  good  water  supply. 

'  16  to  48  minims  following  free  purgation  with  mag.  sulph.  They 
claim  that  this  may  remove  all  amebae,  and  this  treatment  should  be 
given  a  trial. 


\  NOTES  ON  TRANSMISSIBLE  DISEASES  179 

'  4.  Hospitals  should  be  fly-screened.  Disinfect  all  cloth- 
ing soiled  by  dysenteric  discharges.  Disinfect  excreta  imme- 
diately after  passage,  disinfect  bed-pans,  and  be  sure  they  are 
kept  closed  so  that  flies  cannot  gain  access  to  them. 

5.  In  countries  where  human  excreta  are  used  for  fertilizer, 
eat  no  uncooked  vegetables. 

6.  Do  not  eat  or  drink  in  native  quarters.  If  natives  are 
used  for  cooks  or  mess  attendants  they  should  be  examined 
to  exclude  carriers,  and  they  should  always  be  kept  under 
the  closest  supervision  and  be  compelled  to  wash  the  hands 
after  leaving  the  rear. 

7.  Physicians  should  instruct  the  nurses  caring  for  these 
cases  as  to  the  manner  of  spread  of  the  disease,  and  should 
give  the  necessary  orders  to  prevent  their  becoming  infected. 

BACILLARY  DYSENTERY. 

Etiology. — Bacillus  dysenteriae.  This  is  a  group  of  organ- 
isms rather  than  a  single  bacillus,  but  this  is  a  scientific 
rather  than  a  practical  fact.  All  members  of  the  dysentery 
group  may  produce  bacillary  dysentery.  Infection  with  the 
Shiga  type  is  apt  to  be  particularly  severe,  while  infection 
with  the  Flexner  type  is  apt  to  be  relatively  less  severe. 

Method  of  Transmission. — The  disease  can  only  be  acquired 
by  swallowing  bacilli  from  the  excreta  of  a  previous  case. 
Bacillary  dysentery  is  spread  by  precisely  the  same  methods 
as  is  typhoid,  namely,  in  contaminated  food  and  drink,  and 
particularly  by  contact  with  preexisting  cases  or  carriers; 
through  the  employment  of  carriers  in  the  preparation  of 
food  and  drink  and  by  flies. 

Period  of  Incubation. — According  to  the  human  experi- 
ment of  Strong  and  Musgrave  the  incubation  period  is  about 
forty-eight  hours. 

Control. — i.  The  measures  to  be  taken  against  dysentery 
are  precisely  the  same  as  those  against  typhoid  (see  Typhoid), 
with  the  exception  of  vaccination.  A  satisfactory  vaccine 
against  dysentery  has  not  yet  been  worked  out. 


180  SANITATION  FOR  MEDICAL  OFFICERS 

2.  When  a  case  of  dysentery  occurs,  stools  should  be  sent  to 
the  nearest  department  laboratory  following  the  same  direc- 
tions given  in  the  circular  concerning  typhoid.  It  is  impera- 
tive that  the  stools  received  by  the  laboratory  should  be  as 
fresh  as  possible  if  the  organisms  are  to  be  successfully  isolated. 

3.  Should  the  department  laboratory  be  too  far  away  to 
receive  stools  promptly,  and  should  it  appear  that  the  dis- 
ease may  become  epidemic,  the  Chief  Surgeon  should  be 
promptly  notified  in  order  that  a  field  laboratory  may  be 
sent  to  work  out  the  etiology  of  the  disease  on  the  ground, 
to  detect  carriers,  and  to  assist  in  the  control  of  the  disease. 

INFLUENZA. 

Etiology. — Bacillus  influenzae,  or  possibly  a  filterable 
\drus. 

Method  of  Transmission. — ^The  organisms  are  excreted  in  the 
nasal  and  buccal  secretions  and  are  conveyed  to  other  persons 
by  droplets  expelled  in  sneezing  and  coughing  and  by  direct 
contact.  The  fingers  of  the  patient  are  probably  constantly 
infected. 

Period  of  Incubation. — One  to  four  days,  oftenest  three 
or  four  days.     (Osier.) 

Prophylaxis. — Practically  the  same  as  for  common  colds 
(see  Colds),  except  that  as  the  disease  is  much  more  serious, 
isolation  should  be  compulsory  instead  of  optional. 

I.  General  Measures. 

1.  Prevention  of  overcrowding.  (See  note  on  Over- 
crowding.) 

2.  Protection  of  the  men  from  extremes  of  temperature  and 
other  general  hygienic  measures  to  maintain  good  general 
health.     (See  Ventilation.) 

II.  Specific  Measures. 

I .  Notification. — Influenza  is  a  dangerous  epidemic  disease 
and  should  be  reportable.  When  the  attending  surgeon  meets 
with  cases  resembling  influenza,  he  should  notify  the  sanitary 


NOTES  ON  TRANSMISSIBLE  DISEASES  181 

2.  Laboratory  Diagnosis. — Many  cases  of  common  colds 
are  sufficiently  severe  to  resemble  influenza,  and  before 
reporting  cases  as  influenza  an  attempt  should  be  made  to 
verify  the  diagnosis  by  isolating  the  B.  influenzae.  This  is 
not  easy,  as  the  organism  will  only  grow  in  the  presence  of 
hemoglobin,  but  a  man  familiar  with  bacteriological  techiiic 
could  carry  out  this  procedure  in  the  laboratory  of  the  camp 
hospital.  Blood-agar  plates  should  be  used,  the  surface  being 
smeared  with  mucus  collected  by  blowing  the  nose  or  expec- 
torating in  a  sterile  Petri  dish. 

3.  Isolation  of  the  patient  in  hospital. 

4.  If  cases  are  few,  contacts  may  be  isolated  in  detention, 
camps  in  small  groups  for  four  days.    If  influenza  does  not 
develop,  they  may  be  released.    If  cases  are  numerous,  this 
procedure  would  be  of  little  value. 

MALARIA. 

Etiology. — The  disease  is  caused  by  the  malarial  Plas- 
modia, of  which  there  are  three  species:  Plasmodium  vivax 
(Tertian  plasmodium),  Plasmodium  malariae  (Quartan  Plas- 
modium), and  Plasmodium  falciparum  (Estivo-autumnal 
Plasmodium) . 

Method  of  Transmission. — Malaria  is  transmitted  solely 
by  the  bite  of  certain  of  the  mosquitoes  belonging  to  the 
genus  Anophelinae,  which  have  previously  become  infected 
by  biting  another  patient  having~the  sexual  forms  (gameto- 
cytes)  of  the  parasite  in  the  peripheral  blood. 

The  malarial  plasmodium  undergoes  a  double  cycle  of 
development.  The  first  is  an  asexual  cycle  called  schizogony, 
during  which  multiplication  occurs  in  the  human  red  cor- 
puscles, and  the  malarial  paroxysm  occurs  at  about  the  time 
this  cycle  is  completed.  After  this  process  of  asexual  repro- 
duction has  lasted  a  certain  length  of  time,  some  of  these 
forms  undergo  a  differentiation  and  become  sexual  forms 
(gametocy tes) .   The  sexual  cycle  goes  no  further  in  the  human 


182  SANITATION  FOR  MEDICAL  OFFICERS 

host.  However,  should  these  gametocytes  be  taken  into  the 
stomach  of  a  suitable  anopheline  mosquito  (it  is  important 
to  notice  here  that  the  asexual  forms  cannot  develop  in  the 
mosquito)  the  second,  or  sexual,  cycle  called  sporogony  is 
completed  in  the  mosquito.  The  female  or  macrogametocyte 
is  fertilized  by  the  male  or  microgametocyte,  and  the  zygote 
so  produced  penetrates  the  cells  of  the  mosquito's  stomach, 
where  it  develops  and  forms  a  cyst.  The  nucleus  of  this  cyst 
undergoes  several  successive  multiplications,  resulting  in  the 
formation  of  a  large  number  of  spores  or  sporozoites.  The 
cyst  finally  ruptures  and  the  sporozoites  pass  into  the 
celom  or  general  body  cavity  of  the  mosquito,  and  then 
easily  find  their  way  into  the  salivary  glands  which  lie  free 
in  the  celom.  These  sporozoites  are  then  discharged  with  the 
saliva  into  any  person  that  the  mosquito  subsequently  bites, 
they  enter  the  red  corpuscles,  and  the  human  or  asexual 
cycle  is  repeated.  The  cycle  of  development  in  the  mosquito 
lasts  from  ten  to  twelve  days.  From  these  facts  it  will  be 
seen  that  the  continued  propagation  of  malaria  depends  upon 
the  following  factors: 

1.  The  presence  of  numerous  human  beings  infected  with 
gametocytes. 

2.  The  presence  of  numerous  anophelinae  in  which  these 
gametocytes  may  develop. 

3.  Free  access  of  anophelinae  to  infected  human  beings. 

4.  Free  access  of  infected  anophelinae  to  other  non-immune 
human  beings.  If  this  chain  is  broken  at  any  point  the  pro- 
pagation of  the  disease  must  cease.  Corresponding  to  these 
divisions  the  following  campaign  against  malaria  may  be 
mapped  out. 

I.  The  Reduction  oj  the  Number  of  Injected  Human  Beings. — . 
If  mosquitoes  are  exposed  for  any  considerable  length  ofl 
time  to  a  temperature  below  65°  F.  plasmodia  fail  to  develop 
in  them,  and  those  that  have  developed  die.    It  is  only  in  the 
extreme  southern  part  of  the  United  States  and  tropical 


I 


NOTES  ON  TRANSMISSIBLE  DISEASES  183 

countries  generally  in  which  the  temperature  does  not  drop 
below  65  °  F.  For  most  of  the  United  States  therefore  it  may 
be  safely  stated  that  the  length  of  time  during  which  mos- 
quitoes may  serve  as  the  hosts  for  the  malarial  Plasmodium 
does  not  exceed  four  to  six  months.  The  disease  would  there- 
fore become  as  extinct  as  the  dodo  were  it  not  for  the  fact 
that  during  the  other  six  to  eight  months  the  plasmodia  are 
kept  alive  in  human  hosts  who  are  malaria  carriers  and  usually 
persons  who  have  had  malaria  during  the  previous  warm 
season.  The  great  importance  of  the  following  measures  is 
therefore  apparent. 

^  I .  Early  notification  of  all  cases  of  malaria,  with  laboratory 
diagnosis  giving  the  type  of  parasite. 

2.  If  possible  a  survey  of  the  population  to  detect  carriers. 

3.  Efficient  treatment  of  all  cases,  following  each  case  with 
a  malarial  register.  (Form  56,  M.  D.).  If  treatment  is 
efficient  the  disease  wdll  not  become  latent,  gametocytes  will 
not  be  formed,  and  the  case  will  not  become  a  carrier  capable 
of  infecting  mosquitoes. 

•    The  minimum  treatment  recommended  is: 

Quinin,  grains  xxx  daily  until  symptoms  are  gone  and 

Plasmodia  cannot  be  found;  then 

Quinin,  grains  xv  daily  for  two  weeks;  then 

Quinin,  grains  x  daily  for  two  weeks;  then 

Quinin,  grains  vi  daily  for  at  least  two  months. 

II.  Measures    to    be    Taken    against    Mosquitoes. — (See 

Mosquitoes.) 

1.  Methods  directed  against  the  adult  insect. 

2.  Methods  directed  against  the  larva. 

3.  Methods  to  prevent  mosquitoes  from  biting. 
Fortunately  mosquito  extermination  is  not  necessary  in 

order  to  prevent  malaria;  all  that  is  necessary  is  to  reduce 
the  number  of  anophelinae  to  such  a  point  that  the  chain  of 
infection  will  be  broken.  All  of  these  measures  must  be 
combined  with  education  of  the  command  in  order  that  co- 
operation instead  of  opposition  may  be  secured. 


184  SANITATION  FOR  MEDICAL  OFFICERS 

PAPPATACI  FEVER. 

This  disease  is  common  in  Austria,  Italy  and  in  countries 
bordering  on  the  Mediterranean  Sea.  The  disease  is  never 
fatal,  but  like  dengue  causes  great  prostration  and  loss  of 
efficiency  in  the  military  service. 

Etiology. — The  organism  causing  the  disease  is  a  filtrabl-e 
virus  at  present  unknown.  The  virus  is  present  in  the  blood 
of  patients  during  the  first  and  second  clays  of  the  disease  but 
not  later.  After  recovery  the  patient  is  immune  to  further 
attacks. 

Method  of  Transmission. — Phlebotomus  papatasii  (sand  fly) 
is  the  carrier  of  the  disease.  After  feeding  there  is  a  period 
of  from  seven  to  ten  days  before  the  fly  becomes  capable  of 
transmitting  the  disease,  so  that  the  virus  must  undergo  a 
cycle  of  development  in  the  fly.  It  is  not  known  how  long 
the  fly  remains  infective,  but  probably  for  the  rest  of  its  life. 

Incubation  Period. — In  experimental  cases  this  varied 
from  three  days,  sixteen  hours  to  seven  days. 

Prophylaxis. — i.  Screening  of  all  patients  especially 
during  the  first  two  days  of  the  disease. 

2.  General  use  of  screens  to  prevent  the  fly  from  biting. 

3.  Attempts  to  destroy  the  insect. 

A  campaign  against  the  insect  is  difficult  because  of  its 
peculiar  life  cycle.  The  fly  lays  its  eggs  in  damp  earth  in 
the  garden  and  particularly  around  old  walls.  The  larvae 
hatch  out  here,  and  it  is  very  difficult  to  find  and  destroy 
them.  Old  walls  may  be  torn  down  or  may  be  repaired  and 
the  surfaces  smoothed  off  with  concrete. 

Screening. — Ordinary  mosquito  bars  and  netting  will  not 
keep  out  the  Phlebotomus  which  is  a  very  small  fly.  Netting 
for  this  purpose  should  therefore  be  made  of  a  cheap  lawn  or 
other  suitable  material  with  very  fine  meshes. 


NOTES  ON  TRANSMISSIBLE  DISEASES  185 

PNEUMONIA. 

Etiology. — About  90  per  cent,  of  all  lobar  pneumonias 
are  due  to  the  Diplococcus  pneumoniae  or  Pneumococcus,  of 
which  there  are  four  types  that  may  be  identified  by  their 
immunological  reactions.  The  types  of  pneumococci  with 
the  percentage  of  infections  caused  by  each  type  together 
with  the  mortality,  are  indicated  in  the  following  table: 


Percentage 

Mortality 

Type. 

of  cases. 

percentage 

I. 

Pneumococcus,  type  I  . 

30-47 

About  24 

2. 

Pneumococcus,  type  II 

18-39 

"       60 

3. 

Pneumococcus  mucosus 

8-13 

"      6i 

4- 

A    group    of    independent 

varieties  of  pneumococci 

20 

7 

Method  of  Transmission. — Pneumococci  are  commonly 
found  in  the  mouths  of  healthy  individuals,  but  investigation 
indicates  that  the  pneumococci  found  in  individuals  that  have 
not  been  exposed  to  cases  of  pneumonia  all  belong  to  class  4 
comprising  the  heterogeneous  organisms  of  low  \drulence. 
In  persons  who  have  been  exposed  to  cases  of  pneumonia,  the 
more  virulent  types  are  usually  found,  and  the  type  found 
corresponds  to  the  type  of  organisms  infecting  the  case  in 
question.  After  such  an  exposure  the  virulent  type  may 
persist  in  the  sputum  for  a  variable  length  of  time,  during 
which  period  the  individual  is  a  true  carrier.  Examination 
of  the  mouths  of  patients  recovering  from  an  attack  of  pneu- 
monia has  shown  that  they  harbor  the  ^drulent  type  for  from, 
twelve  to  ninety  days.  We  may  conclude  therefore  that  the 
majority  and  most  fatal  cases  of  pneumonia  are  dependent 
upon  either  direct  or  indirect  contact  with  a  pre\dous  case. 

Sanitary  Measures. — Pneumonia  often  occurs  among 
soldiers,  and  under  certain  circumstances  (overcrowding  in 
barracks)  the  disease  tends  to  become  epidemic.  As  the 
disease  is  transmissible  and  has  a  high  mortahty,  all  possible 
precautions  should  be  taken  on  the  appearance  of  a  case  to 
prevent  its  spread. 


186  SANITATION  FOR  MEDICAL  OFFICERS 

I.  With  Regard  to  the  Cases  of  Pneumonia. 

1 .  Prompt  notification  just  as  with  other  infectious  diseases. 

2.  Classification  as  to  type  of  organism  in  the  laboratory. 
Send  the  sputum  to  the  nearest  department  laboratory. 

3.  Isolation  of  the  case  in  hospital  and  the  adoption  of 
antiseptic  practises.  The  sputum  must  be  disinfected  as  for 
tuberculosis.  Physicians  and  nurses  should  wash  their  hands 
after  handhng  cases  of  pneumonia  and  take  all  precautions 
to  avoid  transference  of  organisms  to  their  mouths.  Isolation 
of  patient  to  continue  as  long  as  the  patient  continues  to 
harbor  the  virulent  type  of  pneumococcus.  The  sputum 
of  convalescents  may  be  sent  once  a  week  to  the  nearest 
department  laboratory  until  a  negative  report  is  obtained, 
after  which  the  patient  may  be  returned  to  duty. 

4.  Whenever  possible  deal  with  the  problem  of  carriers. 
The  sputum  of  all  contacts  may  be  sent  to  the  laboratory, 
and  if  virulent  types  of  pneumococci  are  found,  they  may  be 
isolated  if  thought  desirable  until  a  negative  report  can  be 
obtained. 

II.  General  Measures. 

1.  The  prevention  of  overcrowding.      (See  Overcrowding.) 

2.  Education  of  the  men  to  avoid  contact  infection. 
Cultivate  the  habit  of  keeping  the  fingers  away  from  the 
mouth  and  nose  and  avoid  contact  with  intermediate  objects 
such  as  common  drinking  cups,  handkerchiefs,  towels,  etc. 

3.  Take  measures  to  reduce  the  amount  of  dust  in  camp. 
It  is  suspected  that  pneumonia  may  be  carried  by  dust.  It  is 
probably  not  so  transmitted,  as  the  pneumococcus  is  a  very 
delicate  organism  that  cannot  be  expected  to  live  long  outside 
the  body.  But  even  if  this  is  correct  other  diseases  are  carried 
by  dust. 

4.  Increase  the  resistance  or  vital  tone  of  the  men  by  living 
a  normal  life  so  far  as  circumstances  will  permit.  Sufficient 
food,  sleep,  exercise  and  clothing  should  be  provided.  Expos- 
ure and  cold  are  predisposing  causes. 


NOTES  ON  TRANSMISSIBLE  DISEASES  187 

MALTA  FEVER. 

Etiology. — The   Micrococcus   melitensis. 

Method  of  Transmission. — Goats  become  infected  and 
excrete  the  organism  in  the  milk.  The  disease  is  usually 
transmitted  through  the  use  of  goats'  milk,  and  although  the 
organism  is  present  in  the  stools  ot  patients  with  the  disease, 
and  theoretically  might  be  transmitted  as  is  typhoid,  this 
method  of  transmission  is  negligible  except  for  physicians  and 
nurses  in  close  contact  mth  such  cases.  The  British  troops 
at  Malta  had  240  cases  per  annum  before  1906,  but  since 
1906,  when  condensed  milk  only  was  supplied,  the  cases 
have  steadily  decreased,  and  in  1910  only  i  case  was 
recorded. 

Incubation  Period. — Six  to  ten  days.  (Osier.)  Four- 
teen days.  (Castellani  and  Chalmers.)  The  latter  authors 
state  that  monkeys  fed  on  infected  milk  developed  the  disease 
in  fifteen  days. 

Prevalence. — The  disease  is  known  to  exist  in  Texas, 
and  probably  in  other  localities  in  the  United  States.  It 
should  be  suspected  whenever  goat's  milk  is  known  to  be 
used. 

Prohyplaxis. — Measures  to  be  taken  may  be  analyzed 
as  follows: 

I.  With  Regard  to  the  Patient. 

1.  Prompt  notification  of  all  cases. 

2.  Isolate  all  cases,  and  as  excreta  are  infective,  disinfect 
as  in  a  case  of  typhoid. 

3.  Convalescents  may  become  carriers;  do  not  discharge 
patient  until  excreta  are  free  of  M.  mehtensis. 

4.  In  case  of  nursing  mothers,  as  milk  is  infective,  put 
child  on  the  bottle. 

II.  General. 

1.  Avoid  all  use  of  goat's  milk. 

2.  If  goat's  milk  is  used,  it  should  be  sterilized  or  at  least 
boiled. 


188  SANITATION  FOR  MEDICAL  OFFICERS 

3.  Since  dust  may  carry  infection,  all  goat  corrals  should 
be  located  at  a  proper  distance  from  residences  or  habitations. 

4.  After  handling  goats,  always  wash  hands  before  eating. 

5.  Good  w^ater  supply  and  general  hygiene. 
III.   Veterinary  Measures. 

1 .  An  investigation  of  goats  by  serum  and  lacto-agglutina- 
tion  reactions  or  by  blood  or  milk  cultures  to  determine 
carriers. 

2.  Slaughter  of  infected  goats. 

3.  Prevention  of  importation  of  infected  animals. 

4.  Inspection  and  hygiene  of  stables. 

MEASLES. 

Etiology. — The  causal  organism  has  not  yet  been  identi- 
fied. The  experiments  of  Anderson  and  Goldberger  indicate 
that  the  virus  of  measles  is  filtrable.  Their  experiments  on 
monkeys  show^ed  that  the  virus  is  contained  in  the  blood,  and 
in  the  buccal  and  nasal  secretions,  and  that  thirty-six  hours 
after  the  appearance  of  the  exanthem,  the  blood  largely  loses 
its  infectivity.  The  experiments  also  strongly  indicate  that 
the  buccal  and  nasal  secretions  lose  their  infectivity  wdth  the 
beginning  of  convalescence.  Anderson  and  Goldberger  com- 
pletely failed  to  transmit  the  disease  by  means  of  the  "scales. " 
These  experiments  have  been  confirmed  by  other  observers, 
and  the  experimental  facts  taken  with  the  epidemiological 
evidence  warrant  the  following  conclusions: 

Method  of  Transmission. — By  immediate  contact  with 
patients  in  the  prodromal  stage  of  the  disease,  and  by  contact 
with  atypical  and  missed  cases.  Aerial  transmission  is 
possible  for  short  distances  by  infected  droplets  expelled  in 
sneezing  and  coughing,  and  this  is  probably  the  usual  method 
among  soldiers,  especially  when  overcrowded.  We  may  say 
that: 

I.  A  case  of  measles  may  be  in  the  infective  stage  as  early 
as  five  days  before  the  appearance  of  the  exanthem,  but  not 
before  the  appearance  of  prodromal  symptoms  (coryza). 


NOTES  ON  TRANSMISSIBLE  DISEASES  189 

2.  The  height  of  infectivity  occurs  with  the  appearance  of 
the  exanthem. 

3.  The  infectivity  of  the  disease  does  not  extend  beyond 
seven  days  after  the  appearance  of  the  exanthem.  Experi- 
ence of  the  New  York  Board  of  Health  is  that  the  disease  is 
probably  not  infective  five  days  after  the  appearance  of  the 
rash.  On  these  facts  a  rational  campaign  against  the  disease 
may  be  formulated  with  hope  of  success. 

Incubation  Period. — Seven  to  fourteen  days,  oftenest 
fourteen.  (Osier.)  In  254  cases  the  minimal  period  from 
exposure  to  first  symptoms  was  seven  days,  the  maximal 
fourteen  days,  the  average  eleven  days.  The  minimal  period 
from  first  symptoms  to  appearance  of  exanthem  was  one  day, 
maximal  seven  days,  average  three  days. 

Prophylaxis. — This  disease  is  most  common  among  young 
soldiers,  is  often  a  rather  serious  illness,  and  has  caused  more 
trouble  to  mihtary  sanitarians  than  all  the  other  exanthemata, 
because  in  the  past  it  has  been  practically  uncontrollable,  and 
has  almost  always  assumed  epidemic  proportions.  It  is 
beUeved  that  in  the  future  this  may  be  avoided. 

I.  Specific  Measures. 

I.  Prompt  notification  of  all  cases  or  suspects. 

:>..  Isolate  all  known  cases  in  the  hospital,  the  isolation  to 
continue  five  days  after  the  exanthem. 

3.  Determine  so  far  as  possible  all  contacts.  All  tent 
mates  are  contacts. 

4.  Find  out  what  contacts  have  had  measles.  If  this  can 
be  definitely  ascertained,  such  men  need  not  be  isolated  as 
the  immunity  to  measles  is  practically  permanent.  In  case  of 
doubt  or  when  a  history  of  German  measles  is  given,  isolate. 

5.  Place  all  non-immune  contacts  in  a  detention  ward. 
If  necessary,  they  may  be  permitted  to  perform  their  duties 
for  seven  days  after  the  contact  (the  minimum  incubation 
period)  but  thereafter  they  must  be  strictly  isolated  and 
observed  for  ten  days.  If  measles  does  not  develop  within 
eighteen  days  from  last  contact,  they  may  be  released. 


190  SANITATION  FOR  MEDICAL  OFFICERS 

6.  Isolate  in  another  ward  or  tent  all  soldiers  of  the  organi- 
zation who  develop  symptoms  of  coryza,  as  soon  as  the' 
symptoms   appear.     Non-commissioned   officers   should  be , 
instructed  to  watch  for  and  recognize  the  symptoms  of  a  cold, 
so  that  these  cases  may  be  isolated  at  the  earHest  possible 
moment. 

7.  Terminal  disinfection  after  measles  is  useless  and  unnec- 
essary, since  transmission  of  measles  by  third  parties  or  by 
fomites  must  be  exceedingly  rare,  if  it  occurs  at  all. 

II.  General  Measures. — Take  all  possible  steps  to  avoid 
overcrowding.  Not  only  measles  but  all  respiratory  diseases 
are  much  more  apt  to  spread  when  the  men  are  overcrowded. 
(See  Overcrowding.) 

MUMPS. 

Etiology. — The  etiological  agent  is  unknown.  The 
disease  may  be  caused  by  a  filtrable  \drus,  as  Wollstein  has 
succeeded  in  producing  parotitis  in  animals  with  filtered 
bacteria-free  extracts  of  saliva  from  cases  of  mumps. 

Prevalence. — A  disease  of  childhood  and  adolescence. 
In  barracks  the  disease  has  been  known  to  attack  90  per 
cent,  of  the  soldiers,  and  it  very  commonly  occurs  among 
young  recruits.  While  the  disease  is  generally  not  at  all 
serious  in  its  clinical  aspects,  yet  it  causes  great  impairment 
of  efficiency  for  prolonged  periods,  and  for  this  reason  as 
much  care  as  possible  should  be  taken  to  avoid  the  infection, 
and  to  limit  its  spread  should  it  occur. 

Period  of  Incubation. — From  two  to  three  weeks. 
(Osier.) 

Method  of  Transmission. — There  is  little  experimental 
evidence  concerning  the  method  of  transmission,  but  numer- 
ous clinical  observations  indicate  that  the  disease  is  directly 
contagious,  although  the  degree  of  contagiousness  is  probably 
not  great.  There  can  be  little  doubt  that  the  virus  is  present 
in  the  saliva  of  those  infected  and  is  transmitted  by  direct 


NOTES  ON  TRANSMISSIBLE  DISEASES  191 

contact,  by  recent  indirect  contact,  and  perhaps  to  some 
extent  the  droplets  of  saliva  are  conveyed  from  one  patient 
to  another  by  coughing.  Probably  the  chief  vehicle  for  the 
conveyance  of  saliva  from  one  to  another  is  the  fingers.  The 
fingers  are  put  in  the  mouth  for  some  reason,  or  for  no  reason 
at  all,  and  the  virus  is  distributed  to  everything  the  hand 
touches.  The  soldier  spreads  his  saliva  on  his  playing  cards, 
for  example,  and  others  handling  these  cards  transfer^  it 
fresh  and  virulent  to  their  own  mouths.  Common  drinking 
cups,  pencils,  pipes,  spoons  and  other  objects  introduced  into 
the  mouth  soon  after  their  use  by  another  person  all  assist 
in  transferring  the  virus.  Cases  of  mumps  may  remain 
infectious  for  six  weeks  (Osier).  WoUstein  found  by  infecting 
cats  that  the  virus  of  mumps  is  most  readily  detected  in  the 
saliva  during  the  first  three  days  of  the  disease,  less  readily 
on  the  sixth  day,  and  not  at  all  on  the  ninth  day.  It  would 
appear  from  this  that  it  can  only  be  in  exceptional  cases  that 
infectivity  is  retained  for  six  weeks,  probably  due  to  repeated 
auto-infection  of  other  glands.  When  the  swelling  is  bilateral 
it  is  probable  that  an  isolation  period  of  three  weeks  would 
be  sufiicient. 

Control. — I.  General  Measures. — (See  note  on  Over- 
cro wading  and  Contact  Infection.) 

1.  Educate  the  soldiers  to  stop  the  trade  in  saliva.  Post 
notices  in  conspicuous  places,  and  explain  reason  for  rules  in 
informal  talks. 

2.  Take  measures  to  prevent  overcrowding  and  to  give  as 
much  room  as  possible  to  each  man. 

II.  Specific  Measures. — When  a  case  of  mumps  occurs,  if 
the  disease  is  prevalent  among  the  surrounding  population 
and  if  the  soldiers  mix  freely  with  this  population,  isolation 
will  probably  be  of  little  value,  as  fresh  infections  will  continue 
to  be  received  from  outside  the  camp.  But  if  the  camp  is 
located  at  some  distance  from  other  foci  of  infection,  isolation, 
if  prompt,  may  avert  an  epidemic.  Under  these  circum- 
stances— 


192  SANITATION  FOR  MEDICAL  OFFICERS 

1.  Isolate  the  case  in  the  hospital  for  three  to  six  weeks. 

2.  Place  all  his  tent  mates  and  immediate  contacts  who 
have  not  had  mumps  in  a  detention  ward  for  three  weeks. 
Second  attacks  of  mumps  are  very  rare  so  that  all  those  who 
have  had  the  disease  may  be  regarded  as  immune  and  need 
not  be  isolated. 

3.  Should  no  further  cases  develop,  all  may  be  discharged 
at  the  end  of  three  weeks.  Should  secondary  cases  occur 
among  the  contacts  these  must  in  turn  be  isolated  for  three 
to  six  weeks,  and  the  period  of  detention  for  the  remaining 
contacts  should  be  three  weeks  from  the  last  case  of  mumps. 

Note. — If  this  action  is  taken  when  the  first  case  occurs, 
the  prospect  of  checking  the  disease  is  excellent,  as  the  con- 
tagion is  not  very  active,  and  all  infected  cases  may  be 
removed  at  once  from  the  general  command.  But  if  action 
is  delayed  until  a  number  of  cases  occur,  or  if  fresh  cases 
continue  to  be  introduced  from  the  outside,  little  can  be 
expected  of  isolation,  and  the  period  of  incubation  and 
infectiousness  combined  is  so  long  (nine  weeks),  that  isolation 
is  sure  to  become  unduly  burdensome,  as  well  as  ineffective. 

PLAGUE. 

Etiology. — Bacillus  pestis. 

Method  of  Transmission. — In  pneumonic  plague  the  bacilli 
are  present  in  the  sputum  in  great  numbers  and  infection  is 
transmitted  from  one  person  to  another  by  contact  or  by  means 
of  the  droplets  expelled  in  coughing  or  speaking.  Bubonic 
plague  is  contracted  only  through  the  bites  of  fleas  previously 
infected  from  plague  rats.  Plague  is  primarily  a  disease  of 
rats.  Xenopsylla  cheopis,  the  rat  ilea  of  the  tropics,  will  also 
bite  man  readily  and  is  the  common  transmitter  of  plague. 
This  flea  becomes  infected  from  the  rat,  and  leaves  the  rat 
after  its  death  and  often  attacks  man.  Plague  bacilli  develop 
readily  in  the  alimentary  tract  of  the  flea  even  to  the  point  of 
forming  masses  that  cause  an  intestinal  or  pharyngeal  ob- 


NOTES  ON  TRANSMISSIBLE  DISEASES  193 

struction.  The  flea  always  regurgitates  while  feeding,  and  a 
plague-infected  flea  suffering  from  this  obstruction  regurgi- 
tates even  more  than  usual,  and  is  therefore  almost  certain 
to  regurgitate  plague  bacilli  into  the  wound.  Infection  is 
practically  certain  to  follow,  as  man  has  very  little  resistance 
against  these  organisms. 

Period  of  Incubation. — The  possible  variations  in  this 
period  are  not  know^n  with  accuracy,  as  it  is  seldom  known 
w^hen  the  infection  is  received.    The  United  States  Quaran- 
tine Regulations  state  that  seven  days  shall  be  considered 
the  incubation  period  of  plague  for  quarantine  purposes. 
This  may  be  taken  as  the  longest  possible  incubation  period. 
Prophylaxis  and  Control. — Since  plague  is  primarily 
a  rat  disease,  all  sanitary  measures  are  directed  against  that 
animal.    Suppression  of  human  cases  does  not  mean  eradica- 
tion of  plague ;  in  Havana  eighteen  months  elapsed  between 
presumptive  eradication  in   191 2  and  its  reappearance  in 
1 9 14,  while  in  San  Francisco  rodent  plague  was  found  eight 
months  after  the  last  human  case.    The  rodent  case  incidence 
is  therefore  more  significant  to  the  sanitarian  than  the  human 
case  incidence.    Human  cases  may  be  isolated  if  it  is  thought 
i  desirable,  but  no  great  precautions  need  be  taken,  as  the 
I  disease  (unless  pneumonic)  is  practically  never  transmitted 
I  from  man  to  man.    The  following  measures  should  be  taken: 
1     I.  Eradication  of  Disease  when  Already  present. 
j      I .  The  town  should  be  divided  into  districts  with  a  sanitary 
I  officer  in  charge  of  each  district  together  with  the  proper 
i  sanitary  personnel  including  rat  catchers  and  artisans  capable 
of  conducting  rat-proofing  operations. 

}  2.  In  each  district  headquarters  a  map  is  placed,  upon  which 
I  cases  of  human  plague  may  be  spotted  with  pins  of  one  color 
it  and  rat  plague  with  pins  of  another  color. 
I  3.  As  soon  as  a  house  is  spotted  with  either  human  or  rat 
I  plague,  draw  radiating  lines  from  that  point  outw^ard.  The 
jjrat  catchers  work  along  these  lines  and  thus  determine  the 

ii        13 


194  SANITATION  FOR  MEDICAL  OFFICERS 

point  farthest  from  the  infected  center  where  any  infected 
rats  are  found.  Connecting  lines  drawn  between  these  out- 
side points  on  the  radii  determine  the  area  in  which  rat- 
catching  squads  should  concentrate  their  effort?.  It  is  a 
mistake  to  begin  catching  rats  at  the  center,  as  this  merely 
drives  the  rats  farther  out.  Squads  work  inward  from  the 
outside  and  endeavor  to  kill  all  rats.  Hiding  places  are  torn 
open  and  destroyed.  In  Manila  terriers  were  found  very 
useful  to  catch  the  rats  as  they  ran  from  their  hiding  places. 
Houses  may  be  fumigated  and  traps  and  poisons  may  be  used.| 

4.  In  addition  to  this  work  in  infected  foci  a  general  rat- 
catching  campaign  is  conducted  in  each  district  by  means  of 
systematic  trapping,  poisoning  and  other  measures. 

5.  All  rats  caught  or  killed  are  tagged  with  the  location 
where  caught  and  are  immersed  in  a  disinfectant  solution 
to  kill  the  fleas,  after  which  they  are  sent  to  the  central 
laboratory  where  all  rats  caught  must  be  examined  daily 
to  determine  whether  they  are  infected  with  plague.  This 
work  may  be  done  very  rapidly,  and  one  skilled  laboratory 
man  with  several  assistants  to  open  the  rats  can  pass  on 
several  hundred  rats  daily.  When  a  plague  rat  is  found,  the 
tag  is  consulted,  and  the  exact  locality  where  it  was  found  is 
sent  to  district  headquarters.  This  is  spotted  on  the  map  and 
constitutes  a  new  focus  to  be  dealt  with  as  outlined  above. 

6.  As  fast  as  a  particular  locality  is  cleared  of  rats,  it 
should  be  rendered  rat-proof  as  far  as  possible. 

II.  Restrictive  Measures  to  Prevent  the  Entrance  of  Plague. 

I.  Ships. — All  ships  from  plague-infected  ports  should  if 
possible  be  fumigated  before  being  docked.  Either  sulphur . 
dioxide,  carbon  monoxide  or  hydrocyanic  acid  may  be  used, 
and  in  this  way  both  ship  and  cargo  will  be  freed  of  rats.  If 
this  cannot  be  done,  the  ship  should  be  kept  six  feet  from  tht 
dock,  the  hawsers  should  be  fitted  with  rat  guards,  unloading 
should  be  done  only  by  daylight  and  no  gangplank  left  dow: 
at  night.  These  measures  are  all  necessary  to  prevent  rats 
from  leaving  the  ship. 


NOTES  ON  TRANSMISSIBLE  DISEASES  195 

2.  Railroad  Terminals. — All  freight  cars  entering  from 
infected  regions  should  be  fumigated  in  the  same  way  to  kill 
all  rats  before  the  cargo  is  unloaded.  Bagge  cars  may  also 
be  fumigated  if  this  is  considered  necessary.  Cargo  should 
be  required  to  be  stored  in  rat-proof  warehouses  before  and 
after  loading,  which  should  be  done  during  daylight.  Cars 
should  be  constructed  so  that  a  rat  cannot  enter  the  car 
after  it  is  loaded  and  the  door  is  closed.  Undetected  rats  in 
freight  are  often  responsible  for  the  spread  of  infection,  and 
this  was  undoubtedly  the  cause  of  the  reintroduction  of 
plague  in  Manila  after  it  had  been  absent  from  the  city  for  a 
period  of  about  ten  years. 

To  successfully  cope  with  plague,  assume  that  the  entire 
city  is  infected  and  employ  a  maximum  number  of  sanitary 
personnel  at  the  beginning.  By  means  of  widespread  trapping 
and  examination  of  the  daily  catch,  the  infected  areas  can  be 
determined  at  an  early  date  in  the  campaign. 

Trapping. — Is  the  most  dependable  method  for  catching 
rats.  It  is  effective  and  the  catch  is  available  for  examination 
which  is  not  always  the  case  when  poison  is  used.  The  spring 
trap  was  found  most  efficient  in  Manila,  though  all  types  may 
be  used. 

Destruction  of  Harborage. — Remove  old  floors  and  open  up 
hollow  walls  and  ceilings.  This  work  must  be  done  during 
daylight  and  terriers  should  be  used  to  catch  the  rats  that 
endeavor  to  escape. 

Removal  of  Rat  Food. — Every  endeavor  must  be  made  to 

remove  all  sources  of  food.     It  has  been  found  that  rats 

normally  breed  up  to  the  limit  of  the  food  supply,  and  that 

when  a  great  number  are  killed  off,  the  ones  that  are  left 

I  breed  much  more  rapidly  so  long  as  plenty  of  food  is  available. 

t  Garbage  must  be  kept  in  metallic  cans  with  tight  covers. 

I  Groceries,  bakeries,  markets  and  stables  and  establishments 

1  of  like  character  should  be  required  to  have  concrete  floors 

,  with  protected  walls,  ceilings,  roofs  and  doors.    When  plank 


196  SANITATION  FOR  MEDICAL  OFFICERS 

floors  are  used,  they  must  be  well  elevated  with  the  under- 
pining  free,  or  protected  by  a  marginal  wall  of  masonry. 

Rat-proofing. — If  the  rodent  population  is  reduced  to  a 
low  level,  rat-proof  construction  automatically  maintains  this 
low  level.  It  is  impossible  to  eliminate  the  rat,  but  if  the 
rodent  population  is  reduced  50  to  80  per  cent.,  and  congested 
rat  centers  are  eliminated,  plague  will  probably  disappear, 
and  the  rat-proof  construction  will  prevent  any  great  increase 
in  the  rodent  population.  In  protecting  a  building  if  possible 
elevate  it  one  to  three  feet  above  the  ground  and  keep  it 
clear  underneath.  This  eliminates  harborage  under  the 
building.  Or  construct  an  impervious  wall  of  masonary  two 
feet  beneath  the  surface  of  the  earth  and  meeting  the  floor 
flush.  Concrete  floors  are  ideal  and  should  be  required 
where  food  is  stored.  Double  walls  can  be  protected  by  metal 
flashing  at  the  junction  of  the  floor  and  the  wall  where  rats 
begin  to  gnaw,  or  obliteration  of  the  wall  space  may  be  secured 
by  a  concrete  or  brick  fill  extending  upward  one  foot  from  the 
floor  level.  If  the  tiles  of  the  roof  are  infested,  these  may 
be  replaced  by  simple  galvanized  iron  which  does  not  afford 
any  harborage.  Doors  of  warehouses  should  be  sUding, 
close-fitting  and  the  door  sills  should  be  composed  of  concrete, 
and  should  be  raised  several  inches  above  the  ground.  Such 
doors  should  always  be  closed  at  night,  and  should  be  guarded 
by  a  watchman  in  the  daytime.  Rats  are  often  very  bold  and 
will  run  through  these  doors  in  broad  daylight.  This  is  less 
likely  to  happen  if  the  door  siU  is  at  least  six  inches  above  the 
level  of  the  ground. 

RABIES  (HYDROPHOBIA). 

Rabies  is  unusual  among  soldiers,  but  it  may  occur  at  any 
time,  and  as  the  disease  is  always  fatal  after  it  has  once 
developed,  medical  officers  should  know  exactly  what  steps 
to  take  to  prevent  the  development  of  the  disease  in  case 
men  are  bitten. 


NOTES  ON  TRANSMISSIBLE  DISEASES  197 

Etiology. — A  filtrable  virus  is  at  present  unknown.  Negri 
bodies  are  found  in  the  brain  in  all  cases  of  the  disease  and 
may  be  either  a  phase  in  the  development  of  the  organism, 
or  more  probably  a  product  of  its  growth. 

Method  of  Transmission. — The  virus  is  present  in  the  saliva 
of  animals  suffering  with  the  disease,  and  is  inoculated  by  the 
bite  of  the  infected  animal.  The  disease  is  generally  trans- 
mitted to  man  by  the  bite  of  rabid  dogs,  though  sometimes 
by  the  bite  of  rabid  cats,  wolves,  coyotes,  skunks,  and  other 
wild  animals. 

Period  of  Incubaton — The  minimum  is  perhaps  twelve 
days .  The  average  incubation  period  of  5 1  o  cases  was  seventy- 
two  days.  In  exceptional  cases  the  incubation  period  may 
be  very  long  (eight  to  ten  months),  and  at  least  one  case  is 
on  record  that  died  twenty-two  months  after  infection.  The 
length  of  the  incubation  period  depends  upon  the  location  of 
the  bite  (nearness  to  a  nerve  and  to  the  head;  the  virus 
travels  to  the  brain  along  the  nerves),  character  of  the  bite, 
and  presence  or  absence  of  clothing. 

Incubation  Period  in  the  Dog. — When  a  dog  is  bitten  by  a 
rabid  animal  in  the  usual  way,  the  incubation  period  aver- 
ages from  five  to  eight  weeks.  Rabies  develops  within  two 
months  in  83  per  cent,  of  the  cases,  within  three  months  in 
99  per  cent.,  and  the  remaining  i  per  cent,  in  four  months 
or  later. 

Prophylaxis. — 1.  Procedure  to  be  Followed  in  Case  of 
Dog  Bites. — I.  Keep  the  dog  aUve  and  carefully  isolated  and 
watch  for  the  development  of  rabies.  If  the  dog  is  rabid, 
it  will  die  of  the  disease  shortly.  If  the  dog  remains  well  for 
ten  days  it  was  not  rabid. 

2.  If  the  dog  has  been  killed,  send  the  body  if  possible,  and 
at  least  send  the  head  to  the  nearest  department  laboratory 
so  that  the  brain  may  be  examined  for  Negri  bodies,  and  by 
inoculation  experiments  in  rabbits.  Rabbits  are  most 
susceptible  to  this  virus. 


198  SANITATION  FOR  MEDICAL  OFFICERS 

3.  Indications  for  Prophylactic  Treatment. 

(a)  All  cases  in  which  the  dog  has  been  proved  to  be  rabid. 

{b)  All  cases  in  which  nothing  is  know^n  of  the  dog,  espe- 
cially if  rabies  has  already  occurred  in  dogs  or  man  in  the 
vicinity,  or  when  the  dog  has  behaved  in  a  suspicious  manner. 

(c)  If  the  dog  is  well  known  and  does  not  develop  rabies 
in  ten  days,  no  treatment  is  necessary. 

II.  Methods  to  Be  Taken  against  Dogs. — Rabies  can  be 
stamped  out  by  muzzling  all  know^n  dogs  for  a  sufficient  length 
of  time,  and  destroying  all  stray  dogs.  Two  years  after  the 
last  case  the  muzzling  may  be  discontinued.  Therefore 
should  a  case  of  rabies  occur,  all  valuable  dogs  should  be 
muzzled,  and  all  stray  dogs  should  be  killed. 

Results  of  Prophylactic  Inoculation. — i .  With  regard  to  the' 
protection  afforded.     Of  152,829  cases  treated,  705  or  0.46 
per  cent.  died.     Many  of  these  received  the  treatment  too 
late. 

.  2.  With  regard  to  injurious  effects.  The  inoculation  is  not 
devoid  of  danger.  Of  110,000  cases  so  treated,  about  40  have 
developed  paralytic  phenomena.  Moreover,  the  injections 
extend  over  a  considerable  period,  and  are  painful.  There- 
fore avoid  the  use  of  the  prophylactic  except  in  cases  where 
it  is  indicated,  but  in  these  cases  use  it  without  hesitation, 
as  it  affords  a  high  degree  of  protection  and  the  danger  is 
infinitesimal  as  compared  ^^ith  the  danger  of  developing 
rabies.  The  advisability  of  not  killing  the  dog  that  has 
bitten,  but  of  isolating  and  w^atching  it^  cannot  be  emphasized 
too  strongly.  Unfortunately,  most  people  lose  their  heads 
where  this  disease  is  concerned,  and  the  first  impulse  is  always 
to  kill  the  dog.  This  makes  it  much  more  difficult  to  deter- 
mine whether  the  dog  was  rabid  and  whether  the  patient 
tieeds  the  prophylactic  treatment.  Moreover,  if  the  dog  has 
been  killed  it  should  be  shipped  promptly,  and  if  possible 
packed  in  ice  so  that  it  may  arrive  at  the  laboratory  before 
decompositon  has  set  in.  The  search  for  Negri  bodies  is 
much  less  reliable  after  decomposition  has  set  in.    In  this 


NOTES  ON  TRANSMISSIBLE  DISEASES  199 

case,  animal  inoculation  is  all  that  is  left,  and  this  takes 
some  time. 

Method  of  Obtaining  the  Prophylactic  Treatment. — Circular 
No.  9,  W.  D.,  office  of  the  Surgeon-General,  Washington, 
September  19,  191 2.  The  following  information  relating  to 
the  treatment  at  army  posts  of  cases  of  suspected  rabies  is 
published  for  the  information  of  all  medical  officers: 

Through  the  courtesy  of  the  PubUc  Health  Service  the  virus 
will  be  furnished  by  the  Hygienic  Laboratory,  Washington, 
D.  C.  Whenever  antirabic  treatment  for  any  person  at  a  post 
is  deemed  necessary  by  the  surgeon,  he  will  telegraph  a  request 
for  the  same  to  the  director,  Hygienic  Laboratory,  Twenty- 
fifth  and  E  Streets  N.W.,  Washington,  D.  C.  Post  surgeons 
in  the  Western  Division  should  also  telegraph,  at  once,  a 
requisition  to  the  medical  supply  officer,  San  Francisco,  Cal., 
for  the  virus  for  beginning  the  treatment.  This  should  be 
done  in  order  that  the  treatment  may  be  begun  as  early  as 
possible.  The  incubative  period  is  shorter  in  children  and  in 
bites  of  the  face  and  head,  and  wounds  in  these  parts  are  the 
most  dangerous. 

The  animal  that  is  supposed  to  be  rabid  should  be  secured, 
if  possible,  and  kept  under  observation  until  the  diagnosis  can 
be  positively  made.  After  the  death  of  the  animal,  or  if  the 
animal  is  killed  and  it  is  impracticable  to  examine  the  brain 
for  Negri  bodies  at  the  post,  it  should  at  once  be  sent  either 
to  the  laboratory  of  the  Army  Medical  School,  Washington, 
D.  C,  Fort  Leavenworth,  Kan.,  or  the  Letterman  General 
Hospital,  San  Francisco,  Cal.  If  the  brain  will  reach  the 
laboratory  within  twenty-four  hours  it  should  be  carefully 
packed  in  ice,  otherwise  the  brain,  or  at  least  that  portion  of 
it  containing  the  hypocampus,  should  be  placed  in  pure 
glycerin. 

A  careful  record  of  the  case  should  be  kept  describing  the 
injury,  the  treatment,  and  subsequent  history,  with  dates. 
All  the  details  regarding  the  rabid  animal  and  the  data  upon 
which  the  diagnosis  was  made  should  be  included.     Upon 


200  SANITATION  FOR  MEDICAL  OFFICERS 

completion  of  the  treatment  a  copy  of  this  record  should  be 
forwarded  to  the  Surgeon-General  of  the  Army  for  trans- 
mission to  the  director  of  the  Hygienic  Laboratory. 

Directions  for  the  Use  or  Rabies  Virus  Shipped  from 
THE  Hygienic  Laboratory,  Public  Health  Service, 
Washington,  D.  C. — The  virus  should  be  kept  in  an  ice-box 
or  other  cold  place.  This  material  is  perishable  and  must 
not  be  kept  on  hand  for  future  use.  Each  bottle  contains 
the  number  of  doses  required,  until  further  shipments  are 
made,  of  cord  dried  for  the  number  of  days  indicated  on  the 
label.  Further  shipments  of  cord  to  complete  treatment 
already  begun  are  made  without  further  request. 

Dose. — Each  small  section  of  cord  (about  i  to  8  cm.) 
constitutes  one  dose. 

-  The  following  equipment  is  necessary  for  making  and  using 
the  emulsion:  Physiological  salt  solution ;  alcohol;  absorbent 
cotton  or  gauze ;  glass  or  porcelain  mortar  and  pestle  (capacity 
lo  to  20  c.c);  thumb  forceps;  hypodermic  syringe  (at  least 
3  c.c.  capacity),  with  large  needle;  glass  pipette,  5  c.c,  grad- 
uated at  least  to  0.5  c.c. ;  small  conical  test-glass  or  beaker  or 
other  small  container.  These  must  be  sterilized  and  then  the 
instruments,  etc.,  rinsed  in  sterile  salt  solution.  The  technic 
must  be  aseptic  throughout. 

To  Make  the  Emulsion. — Remove  one  section  of  cord  from 
the  bottle  with  the  thumb  forceps  and  rinse  it  free  of  glycerin 
with  sterile  salt  solution  in  the  small  glass  container,  place  it 
in  the  empty  mortar,  and,  without  the  addition  of  any  fluid, 
rub  up  as  finely  as  possible.  Then  2.5  c.c.  of  the  salt  solution 
are  gradually  added  by  means  of  the  pipette,  taking  care 
between  the  additions  of  the  salt  solution  to  rub  to  a 
uniform  consistency.  Draw  all  of  the  emulsion  into  the 
syringe. 

To  Use. — Scrub  the  skin  at  the  site  of  inoculation  with 
alcohol  and  inject  the  emulsion  into  the  subcutaneous  tissue, 
being  careful  not  to  injure  muscular  layers  or  visible  veins. 


NOTES  ON  TRANSMISSIBLE  DISEASES 


201 


Alternate  successive  injections  on  the  two  sides  of  the  anterior 
abdominal  wall.  For  the  schemes  of  injection  see  following 
table: 

SCHEME   FOR   INTENSIVE    TREATMENT. 

Twenty-five  doses. 


Day  of 

Cord 

Number  of 

Amount  injected. 

treatment. 

marked. 

injections. 

Adult. 

5  to  10 
years. 

1  to  5 
years. 

c.c. 

c.c. 

c.c. 

I       .       .       .       . 

8-7-6 

3  injections,  inter- 
val 3  hours 

2-5 

2-5 

2.5 

2       .        .        .        . 

4-3 

2  injections,  inter- 
val 6  hours 

2-5 

2.5 

2.0 

3     .      •      .      • 

5-4 

2  injections,  inter- 
val 6  hours 

2-5 

2.5 

2.5 

4     .      .      .      . 

3 

I  injection 

2-5 

2.5 

2.0 

5     •      .      •      . 

3 

I  injection 

2-5 

2.5 

2.0 

6     .      .      .      . 

2 

I  injection 

2-5 

2.0 

1-5 

7     .      .      .      . 

2 

I  injection 

2.5 

2-5 

2.0 

8     .      .      .      . 

I 

I  injection 

2-5 

1-5 

I.O 

9     .      .      .      . 

5 

I  injection 

.  2.5 

2-5 

2-5 

ID       ...        o 

4 

I  injection 

2.5 

2.5 

2.5 

II       .        .        ... 

4 

I  injection 

2.5 

2.5 

2.5 

12       ...        . 

3 

I  injection 

2.5 

2.5 

2.0 

13     .      .      •      • 

3 

I  injection 

2.5 

2-5 

2.0 

14     ...      . 

2 

I  injection 

2.5 

2.5 

2.0 

15     ...      . 

2 

I  injection 

2.5 

2.5 

2.0 

i6     .      .      .      . 

4 

I  injection 

2.5 

2-5 

2.5 

17     ...      . 

3 

I  injection 

2.5 

2-5 

2.5 

i8     .      .      .      . 

2 

I  injection 

2-5 

2.5 

2.0 

19     ...      . 

3 

I  injection 

2-5 

2.5 

2.0 

20       .        .        .        . 

2 

I  injection 

2.5 

2-5 

2.5 

21        ...        . 

I 

I  injection 

2-5 

2.5 

2.0 

Geo.  H.  Torney, 

Surgeon-General,  United  States  Army. 

Approved:    By  Order  of  the  Secretary  of  War: 
Leonard  Wood, 

Major-Generai,  Chief  of  Staff. 


202  SANITATION  FOR  MEDICAL  OFFICERS 

SCABIES  (SEE  ITCH  MITES). 

Skin  diseases  are  exceedingly  common  under  the  conditions 
of  trench  warfare  and  cause  much  disabihty.  Of  these  condi- 
tions, scabies  has  been  the  most  frequent  on  the  Western 
front.  As  the  result  of  scratching,  secondary  pyogenic 
infections  are  common  and  may  cause  prolonged  sickness. 
Three  or  four  days  are  required  for  treatment  of  a  simple  case, 
but  the  average  stay  in  hospital  of  a  large  number  of  cases 
suffering  from  secondary  pyogenic  infection  was  31.6  days. 

Etiology. — Sarcoptes  Scabiei. — This  mite  lives  in  the 
tunnels  that  it  excavates  in  the  epidermis,  and  attacks  by 
preference  localities  with  thin  skin  such  as  the  wTists,  hands, 
penis,  abdomen,  axillary  borders  and  similar  localities.  The 
tunnels  are  from  a  few  millimeters  to  i  cm.  long  and  are  tor- 
tuous. The  female  is  found  at  the  terminal  end  of  the  tunnel, 
which  also  contains  the  ova  and  the  excrement  deposited. 

Method  of  Transmission. — The  mite  is  transmitted  from 
man  to  man  as  the  result  of  prolonged  and  intimate  bodily 
contact,  or  similar  contact  with  infected  bedding  and  clothing. 
Some  authorities  lay  particular  stress  upon  the  liability  to 
and  frequency  of  infection  during  sexual  intercourse.  On 
the  Western  front  the  occurrence  of  epidemics  among  officers 
sleeping  in  the  same  dugout  indicates  that  infected  bedding 
is  the  source  of  infection  under  such  circumstances. 

Diagnosis. — Scabies  must  be  distinguished  from  pedicu- 
losis, pompholyx,  urticaria  and  straw-itch.  The  papular 
eruption  of  pediculosis  is  rare  on  the  hands,  wrist  and  penis, 
which  are  chiefly  affected  by  scabies.  The  vesicular  lesions  of 
pompholyx  are  deeper  and  more  numerous  than  those  of 
scabies,  and  are  chiefly  limited  to  the  volar  surfaces  of  the 
hands  and  feet.  In  urticaria  the  wTists,  hands  and  penis  are 
not  so  apt  to  be  involved,  and  the  eruption  may  disappear 
suddenly  and  has  a  tendency  to  relapse.  Straw-itch  is  uni- 
versal in  distribution. 


NOTES  ON  TRANSMISSIBLE  DISEASES  203 

I 

Preventive  Measures. — i.  Early  diagnosis  of  all  cases. 
Systematic  physical  inspections  of  the  men  should  be  made 
to  detect  mild  cases  that  may  serve  to  infect  others. 

2.  Segregation  and  treatment  of  all  cases  detected. 

3.  Disinfection  of  all  clothes  and  bedding  of  cases  and 
contacts. 

Treatment. — Sulphur  ointment  has  been  found  to  be  the 
most  effective  treatment,  but  must  be  thoroughly  applied. 
The  patient  is  given  a  thorough  rubbing  with  soap  followed 
by  a  hot  tub  bath,  and  a  scrubbing  with  a  nail  brush  to  open 
the  burrows  and  vesicles.  After  drying,  the  patient  is  given 
a  thorough  inunction  with  sulphur  ointment  from  the  neck 
down,  paying  particular  attention  to  the  infected  parts.  This 
treatment  should  be  repeated  daily  for  three  days,  and  the 
dermatitis  that  nearly  always  follow^s  may  be  treated  with 
zinc  ointment.  It  is  advisable  to  repeat  the  course  of  sulphur 
ointment  after  an  interruption  of  three  or  four  days.  Sulphur 
with  betanaphthol  is  more  effective  than  sulphur  alone. 
The  following  formula  may  be  used:  Betanaphthol  3  parts, 
sulphur  ppt.  10  parts,  zinc  ointment  87  parts.  A  simple  and 
very  effective  mode  of  treatment  consists  in  the  use  of  sulphur 
as  a  pow^der,  with  which  the  entire  body  is  freely  rubbed  once 
a  day  for  a  week  at  bedtime,  the  patient  sleeping  in  contact 
with  the  sulphur  dust.  Fumigation  with  sulphur  in  especially 
made  wooden  boxes  has  been  extensively  employed  in  the 
English  army. 

At  the  conclusion  of  the  treatment  all  clothing  and  bedding 
is  sterilized  by  steam  or  by  boiling.  Leather  gloves  should 
be  sterilized  by  sulphur  fumigation. 

STRAW-ITCH,  GRAIN-ITCH,  MATTRESS-ITCH. 

'  These  names  have  been  used  to  indicate  a  papular  and 
vesicopapular  skin  disease  produced  by  an  acarine  mite, 
pediculoides  ventricosus,  which  is  parasitic  on  the  larvae  of 


204  SANITATION  FOR  MEDICAL  OFFICERS 

various  insects,  especially  the  wheat-straw  worm  and  the 
joint  worm.  The  intensely  pruritic  lesions  are  distributed 
widely  over  the  skin  without  characteristic  localization. 
Pyogenic  infections  are  common  as  the  result  of  scratching. 
The  condition  is  of  importance  not  only  because  it  may  occur 
as  the  result  of  sleeping  on  straw  mattresses  but  because  it 
must  be  distinguished  from  scabies. 

Classification  of  the  Parasite. — Class  Arachnida. 
Order  Acarinae.    Family  Tarsonemidae.     Genus  Pediculoides. 

Method  of  Transmission. — Through  infested  straw  and 
straw  mattresses. 

Preventive  Measures. — Sterilization  or  destruction  of 
straw  mattresses  and  sterilization  of  clothing  by  heat. 

Treatment. — Bathe  with  soap  followed  by  inunction  with 
an  ointment  of  sulphur  ppt.,  lo  per  cent.,  and  betanaphthol, 
I  per  cent.,  in  zinc  ointment.  To  be  used  once  a  day  for  three 
days. 

SCARLET  FEVER. 

Scarlet  fever  is  not  widely  prevalent  in  the  army,  but  cases 
occur  from  time  to  time.  It  is  not  so  highly  infectious  as 
measles  and  does  not  tend  to  become  epidemic  among  soldiers 
who  apparently  have  passed  the  period  of  greatest  suscepti- 
bility. 

Etiology. — The  cause  of  scarlet  fever  is  unknown. 

Method  of  Transmission. — The  evidence  indicates  that  the 
chief  if  not  the  only  source  of  infection  is  the  secretions  of  the 
mucous  membranes  of  the  nose,  throat  and  respiratory  tract, 
and  the  infection  probably  enters  the  body  by  the  same 
routes.  According  to  the  best  opinion  today,  the  desquama- 
tion plays  no  part  in  transmitting  infection.  Fomites  which 
were  formerly  considered  of  great  importance  in  this  disease 
are  probably  a  negligible  factor.  Carriers  and  mild  missed 
cases  undoubtedly  play  a  major  role  in  disseminating  scarlet 
fever,  but  it  is  sometimes  transmitted  by  milk,  the  literature 


NOTES  ON  TRANSMISSIBLE  DISEASES       -'        205 

containing  51  epidemics  believed  to  have  been  caused  by 
milk  supposedly  infected  during  the  handling  prior  to  its  sale. 

Period  or  Incubation. — One  to  seven  days,  oftenest 
two  to  four.     (Osier.) 

Control. 

I.  General  Measures. 

1.  Prevention  of  overcrowding  and  contact  infection. 

2.  Pasteurization  of  all  milk  supplies. 
II.  Specific  Measures. 

1.  Prompt  notification. 

2.  Isolation  of  cases  in  hospital  with  disinfection  of  the 
discharges  from  the  mouth  and  nose.  As  no  one  knows  how 
long  a  case  remains  infective,  the  period  of  isolation  is  largely 
guesswork  and  varies  in  different  cities  from  three  to  eight 
weeks.  Rosenau  states  that  fifty  days  may  be  taken  as  a 
safe  average.  The  Committee  on  Communicable  Diseases  of 
the  American  Public  Health  Association  reported  in  19 13  that 
"  cases  may  be  released  when  abnormal  discharges  have  ceased 
and  the  patient  appears  normal  (even  if  desquamation  is 
incomplete).  A  minimum  of  four  weeks  should,  however, 
be  maintained." 

3.  Isolation  of  contacts  in  small  groups  during  the  iiicuba- 
tion  period  (seven  days).  If  scarlet  fever  does  not  develop 
in  this  time  they  may  be  released. 

4.  Terminal  disinfection  with  formaldehyde  may  be 
practised  if  desired,  but  is  probably  useless. 

SMALLPOX. 

Smallpox  is  almost  never  seen  in  the  army,  as  the  entire 
personnel  is  vaccinated,  but  it  may  be  encountered  among  the 
native  population  in  many  places  where  the  army  may  be  sent. 

Etiology. — The  etiological  agent  is  still  unknown. 

Method  of  Transmission. — Is  also  unknown,  although  it  is 
known  that  the  disease  is  very  contagious, 


206  SANITATION  FOR  MEDICAL  OFFICERS 

Incubation  Period.^— Nine  to  fifteen  days,  oftenest 
twelve  days.     (Osier.) 

Prophylaxis. — Vaccination  is  a  sovereign  prophylactic. 
When  performed  in  a  systematic  way  (revaccination),  small- 
pox is  unknown. 

Duration  of  the  Immunity  A  forded  by  Vaccination. — 99.9  of 
those  never  vaccinated  will  take  if  the  vaccine  is  potent.  Of 
those  vaccinated  after  one  year  14  to  28  per  cent,  take  when 
revaccinated.  After  five  years,  50  to  51  per  cent,  take  when 
revaccinated ;  after  ten  years,  85  to  89  per  cent,  take  when 
revaccinated. 

Rules  for  Revaccination. — i.  The  general  population  should 
be  vaccinated  about  every  five  years  if  smallpox  is  present 
in  the  community.  In  the  army  all  recruits  must  be  vac- 
cinated when  enUsted,  and  all  soldiers  upon  reenlistment. 
(See  par.  92,  M.  M.  D.,  191 6.)  Medical  ofiicers  should  be 
on  guard  to  see  that  these  regulations  are  comphed  wdth. 
When  in  contact  with  a  population  having  smallpox,  occa- 
sional cases  do  occur  in  the  army,  in  every  case  due  to  the 
fact  that  this  regulation  has  not  been  strictly  complied  with. 

2.  Anyone  directly  exposed  to  smallpox  should  be  vacci- 
nated at  once  if  a  successful  vaccination  has  not  been  made 
within  nine  months.  This  vaccination  should  be  made  at 
once,  as  the  protection  conferred  depends  upon  the  interval 
between  infection  and  the  vaccination.  If  vaccination  is 
performed  within  four  days  after  exposure,  a  successful 
vaccination  may  protect  against  the  disease.  After  a  longer 
interval  smallpox  develops,  but  in  a  somewhat  modified  form. 

3.  When  the  army  enters  a  territory  where  smallpox  is 
prevalent  among  the  natives,  a  general  vaccination  of  the 
population  should  be  made  for  their  own  sake  and  to  protect 
the  command. 

Ta  Obtain  Vaccine  Virus. — Smallpox  vaccine  ^\^[ll  be  asked 
for  by  letter  addressed  to  the  Department  Surgeon.     On 


NOTES  ON  TRANSMISSIBLE  DISEASES  207 

account  of  the  liability  of  this  product  to  become  inert,  only 
such  quantities  as  are  needed  for  early  use  will  be  asked  for. 
1  Isolation. — Smallpox  is  infectious  from  the  earUest  mani- 
festations of  the  disease  until  all  crusts  are  removed.  Isola- 
tion should  cover  this  entire  period.  Those  who  have  been 
exposed  should  be  placed  in  a  detention  camp  and  watched 
for  sixteen  days.  The  Quarantine  Laws  and  Regulations  of 
the  United  States,  1910,  p.  40,  give  fourteen  days  as  the  , 
incubation  period  of  smallpox  for  quarantine  purposes. 

TETANUS. 

Etiology. — Bacillus  tetani. 

Method  of  Transmission. — The  organism  is  a  spore-bearer 
and  can  Uve  for  long  periods  in  the  ground.  It  is  commonly 
found  in  the  intestinal  tract  of  horses  and  other  animals, 
so  that  the  soil  of  cultivated  lands  where  manure  has  been 
used  is  frequently  highly  infectious.  At  the  beginning  of  the 
war  tetanus  was  quite  common  among  wounded  soldiers, 
owing  to  the  fact  that  clothes  and  wounds  were  all  con- 
taminated with  this  infected  mud  from  the  trenches.  Gas 
bacillus  infection  (B.  aerogenes  capsulatus  Welch)  is  acquired 
in  precisely  the  same  way. 

Incubation  Period. — One  to  twenty  days.  The  average 
incubation  period  of  43  fatal  cases  was  8.8  days  and  that  of 
26  cases  that  recovered  was  11.5  days. 

Prophylaxis. — i.  Specific. — All  suspicious  wounds-,  i.  e., 
all  lacerated,  contused,  and  punctured  wounds  inflicted  under 
such  circumstances  that  soil  or  dirt  may  have  been  intror 
duced  require  prophylactic  treatment.  In  the  EngUsh  service 
it  has  been  directed  that  a  dose  of  antitoxin  be  given  to  every 
wounded  man.  This  should  be  given  subcutaneously  at  a 
distance  from  the  wound  at  the  earliest  possible  moment. 
(First-aid  Station  or  Dressing  Station);  500  to  1000  units 
may  be  given.  The  EngHsh  have  found  a  dose  of  500  units 
satisfactory,  and  since   adopting   this   practice   during  six 


208  SANITATION  FOR  MEDICAL  OFFICERS 

months  the  English  army  had  only  36  cases  of  tetanus 
among  those  wounded  who  received  the  antitoxin  within 
twenty-four  hours  after  injury.  More  recently  a  second 
dose  of  500  units  is  given  when  the  patient  arrives  at  the 
base  hospital,  if  the  wound  is  of  any  severity. 

2.  General. — Wounds  should  be  freely  opened,  thoroughly 
cleaned  and  properly  drained  at  the  earUest  possible  moment. 
This  also  aids  in  preventing  gas  bacillus  infection.  Both  of 
these  organisms  are  strict  anaerobes  and  can  therefore  only 
develop  in  the  depths  of  wounds. 

TUBERCULOSIS. 

There  has  been  a  great  increase  in  the  number  of  soldiers 
suffering  from  tuberculosis  as  the  result  of  war  conditions  in 
Europe.  Many  factors  have  contributed  to  this  increase, 
including  overcrowding,  undernourishment  (particularly  in 
prison  camps),  exposure,  and  insufficient  facilities  for  the 
diagnosis,  segregation,  and  treatment  of  already  existing 
cases.  Many  of  these  conditions  are  unavoidable,  owing  to 
military  necessity,  but  sanitary  ofl&cers  should  exert  all 
possible  efforts  to  minimize  these  conditions,  as  the  extension 
of  the  disease  will  prove  a  serious  menace  to  the  efl&ciency 
of  the  command. 

Etiolog\. — Bacillus  tuberculosis. 

Method  of  Transmission. — The  evidence  at  hand  indicates 
that  the  respiratory  tract  is  the  route  of  infection  in  the 
majority  of  cases,  the  organism  being  transmitted  by  dried 
and  pulverized  sputum  or  by  droplet  infection.  It  may  be 
transmitted  by  milk,  and  perhaps  about  7  per  cent,  of  tuber- 
culosis in  man  is  of  bovine  origin;  but  the  great  majority  of 
these  bovine  infections  consist  of  generalized  abdominal  and 
glandular  tuberculosis  in  children,  scarcely  any  being  pulmo- 
nary. It  must  not  be  forgotten  that  many,  perhaps  the 
majority,  of  adults  are  already  infected  and  suffer  from  a 
small  wailed-off  lesion  or  a  latent  focus  which  under  ordinary 


NOTES  ON  TRANSMISSIBLE  DISEASES  209 

\  circumstances  of  life  would  never  cause  any  trouble,  but  which 
\develop  into  an  acute  pulmonary  infection  when  the  resist- 
ance is  diminished  by  the  strains,  exposure  and  increased 
exertions  incident  to  war. 

Prophylaxis. — ^I.  Restriction  of  the  Spread  of  the  Tubercle 
Bacillus. — I.  Diagnosis  of  Existing  Cases. — Provision  should 
be  made  for  the  examination  of  sputum.  In  concentration 
camps  the  sputum  may  be  examined  in  the  camp  hospital 
or  may  be  sent  to  the  nearest  department  laboratory.  In 
active  service  provision  should  be  made  for  the  examination 
of  sputum  at  the  field  hospitals.  A  microscope,  glass  sUdes, 
sputum  bottles  and  a  few  simple  stains  (carbol-fuchsin  and 
methylene  blue)  are  all  that  are  required  for  this  purpose. 
The  sputum  of  all  men  who  have  had  a  cough  four  weeks 
or  more  should  be  examined. 

2.  When  tubercle  bacilli  have  been  detected  in  the  sputum, 
the  man  should  be  removed  to  a  base  hospital  or  sanatorium. 
If  this  is  not  done,  the  man  will  certainly  serve  as  an  active 
focus  of  infection  to  his  comrades  under  the  conditions  of 
camp  or  trench  life.  Here  all  sputum  will  be  disinfected, 
and  the  man  educated  to  avoid  infecting  others. 

3.  The  prevention  of  promiscuous  spitting.  Spitting  should 
be  prohibited  by  order,  and  the  order  enforced  as  far  as 
possible.  In  addition  the  men  should  be  educated  to  under- 
stand that  spitting  spreads  tuberculosis  and  other -diseases. 

II.  Promotion  of  the  Vital  Resistance  of  Individual  Soldiers. 
— So  far  as  war  conditions  permit,  sanitary  officers  must 
take  steps  to  prevent  overcrowding,  defective  ventilation, 
underfeeding,  exposure,  loss  of  sleep  and  other  generally 
unheal thful  conditions.  SunUght  is  a  good  disinfectant,  and 
camp  orders  provide  for  the  sunning  of  tents,  bedding  and 
equipment. 
14 


210  SANITATION  FOR  MEDICAL  OFFICERS 

TYPHUS  FEVER. 

Etiology. — The  organism  causing  this  disease  is  possibly 
an  anaerobic  bacillus  isolated  by  Plotz,  although  this  is  not 
accepted  by  all  authorities. 

Method  of  Transmission. — It  has  been  definitely  proved  that 
typhus  is  transmitted  by  infected  lice.  Infection  occurs 
either  as  the  result  of  the  bite  or  of  crushing  lice  upon  the 
skin  and  rubbing  in  the  excreta  during  scratching.  Lice 
that  have  been  infected  are  capable  of  transmitting  the  infec- 
tion for  at  least  eleven  days,  and  probably  longer.  P.  vesti- 
menti  is  the  usual  transmitter,  but  typhus  may  be  trans- 
mitted by  P.  capitis.  All  evidence  indicates  that  the  disease 
cannot  be  acquired  in  any  other  method  than  by  the  bite  of 
fece  that  have  become  infected  from  a  previous  case.  The 
virus  exists  in  the  circulating  blood  during  the  period  of  the 
fever,  and  probably  for  thirty-six  hours  after.  Lice  feed  daily 
or  oftener,  therefore  if  a  louse  that  has  bitten  a  typhus  case 
gains  access  to  another  man,  it  is  practically  certain  to  bite 
him  and  infect  him  within  a  few  hours.  It  might  be  supposed 
that  this  infection  would  be  easy  to  avoid,  but  experience 
has  shown  that  the  reverse  is  the  case.  There  is  no  disease 
that  has  numbered  more  victims  among  attending  physicians 
and  nurses  than  typhus,  and  where  soldiers  are  closely  con- 
gregated the  difficulty  in  preventing  infestation  is  enormous. 
Peacock  examined  the  men  of  one  division  in  the  trenches  in 
France  and  found  95  per  cent,  of  the  men  infested  wdth  an 
average  of  twenty  lice  per  man.  Five  per  cent,  were  maximum 
cases,  the  number  of  lice  ranging  from  200  to  10,000  per  man. 
The  main  source  of  infection  is  the  soldier  himself,  particularly 
this  small  percentage  that  are  grossly  infested  and  serve  as 
carriers.  Infinite  precautions  must  therefore  be  taken  to 
prevent  this  infestation. 

Incubation  Period. — Five  to  fifteen  days,  usually  nine 
to  twelve  days. 


NOTES  ON  TRANSMISSIBLE  DISEASES  211 

Prophylaxis. — All  measures  of  prevention  are  centered 
Upon  the  louse  as  follows: 

I.  Measures  for  the  prevention  of  lice  infestation  among 
the  soldiers  in  general. 

{a)  Keep  hair  short. 

(b)  Change  and  launder  all  underclothing  at  least  once  a 
week  when  possible.  Iron  clothes,  including  trousers  and 
shirts,  particularly  over  the  seams,  to  kill  eggs. 

(c)  Each  man  should  search  his  clothing  daily  for  lice  or 
nits;  pay  special  attention  to  seams  particularly  at  the  fork 
of  the  trousers. 

(d)  When  soldiers  are  compelled  to  sleep  close  together  and 
clothes  cannot  be  changed,  as  in  the  trenches,  infestation  may 
be  prevented  by  the  use  of  naphthalin.  Naphthalin  kills 
adult  lice  but  does  not  kill  the  eggs.  The  naphthalin  must 
therefore  be  applied  at  intervals  of  four  days  on  the  principle 
of  fractional  steriUzation.  Before  going  to  sleep,  introduce 
a  handful  of  finely  powdered  naphthalin  into  the  clothes 
through  the  opening  at  the  neck.  The  naphthalin  evaporates 
and  kills  adult  lice.  The  advantages  claimed  f.or  this  method 
are  that  it  is  cheap,  requires  neither  special  apparatus  nor 
place,  does  not  injure  either  the  man  or  his- clothing,  and  does 
not  interfere  with  the  service  efficiency  of  the  man.  The 
British  have  found  the  following  N.  C.  I.  powder  to  be  most 
effective:  It  is  composed  of  naphthalin  96  parts,  creosote 
2  parts,  iodoform  2  parts.  This  powder  is  dusted  into  the 
clothes,  but  care  must  be  used  to  avoid  the  crotch,  where 
this  powder  causes  much  smarting.  Crude  oil  ointment  may 
be  used  about  the  crotch.  Two  pounds  of  soft  paraffin 
are  melted  and  4  ounces  of  crude  tar  oil  are  added.  This  is 
also  most  effective,  and  the  use  of  the  ointment  and  powder 
combined  will  keep  the  men  free  of  lice. 

(e)  In  trenches  and  similar  places  a  man  should  be  ap- 
pointed to  distribute  this  powder,  and  company  officers  should 
see  that  their  men  use  proper  precautions  as  outlined  above. 


212  SANITATION  FOR  MEDICAL  OFFICERS 

if)  A  general  inspection  for  lice  once  a  week  is  recom- 
mended. 

(g)  Stations  for  Debusing.  Bathing  facilities  must  be  pro- 
vided at  some  place  for  the  men.  Arrangements  should 
be  made  so  that  while  the  bath  is  being  taken,  the  clothes 
may  be  passed  through  a  steam  sterilizer.  When  the  bath 
is  finished  the  men  pass  into  a  dressing  room,  where  clean 
clothes  are  issued.  The  hair  should  be  cut  and  treated 
before  the  bath.  The  Germans  are  said  to  have  employed 
these  measures  on  a  large  scale  by  converting  factories  into 
stations  for  delousing,  and  it  is  claimed  that  some  of  these 
stations  were  able  to-  bathe  and  sterilize  the  clothes  of  from 
12,000  to  15,000  men  in  one  day. 

II.  Destruction  of  all  lice  and  eggs  found  on  bodies,  cloth- 
ing, bedding,  and  surroundings  of  all  cases  of  typhus,  typhus 
suspects,  and  contacts. 

(a)  Prompt  notification  to  sanitary  authorities  of  all  cases 
or  suspected  cases  of  typhus.  All  cases  of  fever  are  suspects 
in  the  presence-  of  an  epidemic.  Such  cases  with  all  bedding 
and  clothing  should  be  removed  to  the  hospital. 

(b)  All  contacts  with  these  cases  should  be  removed  to  a 
detention  ward  or  camp,  with  their  bedding  and  clothing. 
Contacts  should  be  kept  under  observation  at.  least  twelve 
days. 

(c)  Destruction  of  All  Lice  and  Eggs. — Hospitals  and 
detention  camps  must  be  equipped  to  perform  this  work 
efficiently.  For  treatment  of  bedding  and  clothing,  steam  is 
the  method  of  choice.  When  steam  is  not  available,  clothes 
may  be  boiled  or  dipped  in  gasaline.  No  single  method  is 
absolutely  satisfactory.  Sulphur  fumigation  kills  adult  lice 
but  does  not  kill  the  eggs,  and  in  addition  injures  some  fabrics. 
Steam  ruins  leather  leggings,  shoes  and  hats.  Hot  air  is 
difficult  to  control;  too  great  heat  injures  fabrics  and  too 
little  fails  to  kill  lice.    Hence  methods  must  be  combined  if 


NOTES  ON  TRANSMISSIBLE  DISEASES  213 

delousing  is  to  be  efficient  without  damaging  equipment. 
The  following  method,  based  on  that  in  use  at  the  Quarantine 
Station  at  New  York,  is  suggested  because  it  has  proved 
efficacious.  Out  of  4000  baths,  not  a  single  case  of  typhus 
has  developed  outside  the  incubation  period: 

On  arrival  of  contacts  or  cases  each  man  is  given  an  open- 
mesh  cotton  bag,  24  to  30  inches,  into  which  all  cotton  and 
woolen  goods  of  all  kinds,  including  those  from  lockers  or 
trunks,  are  put.  Lockers,  trunks,  shoes,  and  leggings  may  be 
transferred  to  a  closed  room  and  fumigated  overnight,  burn- 
ing 8  pounds  of  sulphur  to  1000  cubic  feet.  The  mesh  bag 
containing  all  clothes  is  tagged  with  a  number  on  a  metal 
tag,  the  dupHcate  being  given  to  the  man  to  hang  about  his 
neck.  The  bag  is  placed  in  the  sterilizer,  and  the  men  then 
pass  stripped  into  a  shower-bath  room,  where  the  attendant 
examines  the  hair  to  see  if  lice  are  present.  If  Uce  are  found, 
the  hair  is  chpped  short  wdth  No.  00  clippers,  the  hair  dropping 
on  a  paper,  which  is  then  rolled  up  and  burned.  After  being 
passed  through  this  process,  liquid  soap  is  sprayed  upon  the 
body  from  an  elevated  reservoir,  and  the  man  proceeds  to  the 
baths.  The  soap  container  may  be  a  5-gallon  can  with  a  tube 
from  the  bottom  mth  clip  and  spray  attachment.  The  soap 
may  be  made  by  boiling  i  part  soap  chips  in  4  parts  of  water 
and  then  adding  2  parts  of  kerosene  oil.  This  jelUes  when 
cold,  and  i  part  of  this  soap  jelly  is  added  to  4  parts  of  warm 
water,  making  a  good  liquid  soap  for  this  purpose.  Mean- 
while the  clothes  are  disinfected  by  steam  under  pressure, 
dried  in  vacuo,  and  when  the  bath  is  finished  the  men  pass 
from  the  bath  room  into  the  clean  room  and  receive  their 
clothes.  Before  clothes  are  put  in  the  bag  for  sterihzation, 
all  money  and  other  valuables  must  be  removed.  They  may 
be  dipped  in  50  per  cent,  alcohol,  if  considered  necessary,  and 
should  be  kept  in  a  sealed  envelope  mth  the  owner's  name 
plainly  written  on  it.    A  thorough  inspection  of  each  deten- 


214  SANITATION  FOR  MEDICAL  OFFICERS 

tion  is  made  daily  for  lice  and  the  temperature  is  taken  both 
night  and  morning.  All  typhus  suspects  and  cases  must  be 
thoroughly  deloused  before  adinission  to  hospital  or  detention 
wards.  If  no  lice  are  admitted  the  disease  cannot  spread, 
and  further  isolation  is  therefore  unnecessary.  However, 
if  such  patients  are  admitted  to  a  general  ward,  all  patients 
admitted  must  be  deloused,  in  order  that  there  may  be  no 
possibility  of  the  typhus  patient  contracting  a  fresh  infes- 
tation from  some  other  patient. 

III.  Adoption  of  measures  by  persons  in  contact  with 
typhus  (doctors  and  nurses)  to  prevent  the  possibility  of 
their  being  bitten  by  lice. 

1.  Doctors,  nurses,  and  those  engaged  in  the  process  of 
delousing  should  employ  the  following  precautions:  The 
hair  should  be  worn  very  short,  and  clothes  should  be  worn  in 
such  a  manner  that  a  louse  cannot  bite  or  gain  access  to  the 
interior  of  the  clothing.  For  this  purpose  boots  preferably 
of  rubber  should  be  worn,  with  an  operating  gown  or  white 
coat  tightly  fastened  at .  the  wrists,  and  if  possible,  with 
rubber  gloves  on  the  hands  and  fitting  over  the  sleeves.  A 
muslin  cap  should  be  worn  which  will  cover  all  the  hair,  leav- 
ing only  the  face  exposed. 

2.  Care  should  be  exercised  to  avoid  allowing  the  clothing 
to  touch  patients,  furniture,  bedding,  or  clothing  that  is 
known  or  suspected  to  be  infected. 

3.  After  going  off  duty  the  gown,  cap,  and  gloves  may  be 
boiled,  and  the  boots  should  be  washed  off  with  kerosene  or 
bichloride,  and  a  careful  inspection  of  the  person  and  clothing 
for  vermin  must  be  made.  A  bath  and  complete  change  would 
be  advisable  when  possible. 

TYPHOID  FEVER. 

Etiology. — Bacillus  typhosus.  The  same  clinical  con- 
dition may  also  be  produced  by  the  B.  para  typhosus  A.  or 
the  B.  parathyphosus  B. 


NOTES  ON  TEANSMISSIBLE  DISEASES  215 

Method  of  Transmission. — The  bacilli  from  the  excreta  of  a 
previous  case  must  be  swallowed.  Typhoid  may  be  trans- 
mitted through  water,  milk,  infected  food,  or  by  direct  con- 
tact with  a  case  of  the  disease  or  with  a  carrier.  As  water  and 
milk  supplies  are  generally  closely  supervised,  the  usual 
method  of  transmission  among  soldiers  is  by  contact  and  by 
infected  food  or  drink.  These  may  become  infected  directly 
by  carriers  or  indirectly  by  fhes.  Reed  Vaughn  and  Shake- 
speare showed  that  most  of  the  typhoid  contracted  during 
the  Spanish  War  was  contact  infection.  Probably  every 
regiment  brought  into  camp  one  or  more  mild  unrecognized 
cases  or  carriers,  and  these  were  the  starting-point  of  out- 
breaks. Of  1608  cases  studied,  35  per  cent,  were  directly 
connectible,  and  27.8  per  cent,  more  were  indirectly  con- 
nectible;  so  that  62.8  per  cent,  of  the  cases  were  spread  by 
contact.  Owing  to  the  unsatisfactory  methods  of  excreta 
disposal,  the  shoes,  clothing  and  hands  of  the  men,  and  even 
blankets  and  tentage,  became  soiled  with  the  excreta,  and  by 
such  contacts  infection  became  unavoidable.  The  majority 
of  the  remaining  cases  were  probably  transmitted  by  flies 
directly  from  the  latrines  to  the  food. 

Period  of  Incubation. — Eight  to  fourteen  days,  some- 
times as  long  as  twenty-three  days.     (Osier.) 

Control. 

I.  The  provision  of  pure  food  and  drink. 

1.  The  water  supply  must  be  above  suspicion,  or  must  be 
purified.     (See  notes  on  Purification  of  Water.) 

2.  If  milk  be  used,  it  should  be  under  strict  sanitary  super- 
vision and  preferably  pasteurized. 

3.  All  sale  of  food  and  drink  by  unlicensed  venders  must  be 
prohibited.  If  the  sale  of  such  articles  as  ice-cream  and  soft 
drinks  is  permitted,  these  must  be  under  the  direct  supervision 
of  the  sanitary  oflicer. 

II.  A  satisfactory  and  sanitary  disposition  of  all  excreta 
must  be  attained.    (See  Methods  for  the  Disposal  of  Excreta.) 


216  SANITATION  FOR  MEDICAL  OFFICERS 

The  strictest  precautions  must  be  taken  to  keep  the  rears 
and  urinals  in  a  sanitary  condition. 

III.  In  order  to  prevent  contact  infection  from  soiled 
hands,  provision  must  be  made  for  washing  the  hands  after 
lea\dng  the  latrine,  and  also  before  meals,  and  this  rule  must 
be  enforced. 

IV.  Prevention  of  fly  transmission. 

1.  Methods  to  prevent  fly  breeding  and  to  kill  adult  flies. 
(See  Flies.) 

2.  Screening  of  kitchens  and  mess  halls  to  prevent  all 
access  to  food. 

3.  All  latrines  to  be  kept  fly- tight,  by  screening  if  necessary, 
to  prevent  all  access  of  fhes  to  feces. 

4.  Rigid  enforcement  of  the  rule  prohibiting  all  soiling  of 
the  ground  wdth  excreta  or  kitchen  wastes. 

V.  Management  of  Carriers. — When  large  bodies  of  men 
are  assembled,  it  is  inevitable  that  they  will  include  a  certain 
percentage  of  carriers.  It  has  been  estimated  that  from  i  to 
500  to  I  to  250  of  the  population  are  typhoid  carriers.  There- 
fore should  a  case  of  typhoid  appear  in  a  company: 

1.  Examine  stools  and  urine  of  entire  company  if  prac- 
ticable. If  not,  the  stools  and  urine  of  all  cooks,  mess  attend- 
ants, and  those  concerned  in  the  handling  or  serving  of  food 
must  be  examined.  Specimens  of  stools  and  urine  should  be 
sent  to  the  nearest  department  laboratory  in  accordance  with 
the  directions  contained  in  the  following  circular. 

2.  If  a  carrier  is  detected,  he  should  be  isolated  in  the 
hospital  at  once  until  discharged. 

3.  No  case  of  typhoid  is  to  be  discharged  from  the  hospital 
until  three  successive  negative  stool  and  urine  examinations 
have  been  secured,  in  accordance  with  the  directions  in  the 
same  circular. 

4.  All  carriers  detected  should  be  discharged  from  the 
mihtary  service,  since  at  present  there  is  no  satisfactory 
method  of  treating  these  men,  and  they  are  a  permanent 
source  of  danger. 


NOTES  ON  TRANSMISSIBLE  DISEASES  217 

VI.  Management  of  typhoid  cases  in  hospital. 

1.  Surgeons  should  instruct  nurses  and  orderlies  with 
regard  to  the  precautions  to  be  taken  to  avoid  infection. 

2.  Prompt  disinfection  of  all  excreta  immediately  after 
passage.  Qisinfect  bed-pans,  and  keep  same  closed  to  prevent 
access  of  flies. 

3.  Hospitals  should  be  fly  screened  if  possible. 

VII.  Vaccination. — (See  Circular  No.  16,  W.  D.,  Office  of 
S.  G.,  March  20,  1916.) — All  men  are  already  vaccinated 
against  typhoid  in  accordance  with  regulations.  The  pro- 
tection thereby  afforded  is  very  great,  but  it  is  not  absolute, 
hence  other  precautions  should  not  be  relaxed.  Moreover, 
the  typhoid  vaccine  does  not  protect  against  the  paratyphoid 
infections,  dysentery,  and  other  infections  that  are  trans- 
mitted in  the  same  manner  as  typhoid. 

Circular  No.  11,  W.  D.,  office  of  the  Surgeon-General, 
Washington,  February  24,  1913. 

Diagnosis  of  Typhoid  and  Paratyphoid  Fever. — ^There 
were  among  the  61,405  officers  and  enUsted  men  stationed  in 
the  United  States  (Continental)  18  cases  of  typhoid  fever 
during  the  calendar  year  1912;  twelve  of  these,  with  3 
deaths,  occurred  among  the  small  number  of  individuals  who, 
for  one  reason  or  another,  were  not  immunized,  5  being 
recruits  who  were  infected  prior  to  enlistment.  There  were 
6  cases  occurring  in  immunized  persons,  wdth  no  death.  It 
is  quite  probable  that  some  of  these  cases  may  have  been 
paratyphoid  fever,  as  the  latter  can  only  be  excluded  with 
certainty  by  cultural  methods. 

The  practical  extinction  of  typhoid  fever  in  the  army 
affords  an  excellent  opportunity  to  study  the  prevalence  and 
distribution  of  paratyphoid  fever  in  the  United  States,  as 
well  as  to  clear  up  the  etiology  of  the  fevers  of  undetermined 
causation.  The  Widal  reaction  being  of  no  value  in  immu- 
nized persons,  some  other  method  of  diagnosis  is  necessary  to 
distinguish  between  typhoid  and  paratyphoid  and  other 


218  SANITATION  FOR  MEDICAL  OFFICERS 

continued  fevers.  This  is  best  accomplished  by  blood 
cultures,  and  it  is  desired  that  medical  officers  make  use  of 
them  to  a  greater  extent  than  is  now  the  case. 

Each  post  in  the  United  States  should  have  on  hand  at  all 
times  a  few  standard  bottles  of  bile  media  for  use  in  making 
such  cultures.  Full  directions  for  use  will  be  furnished  with 
each  bottle.  Requisitions  should  be  made  immediately  by 
information  slip  for  an  adequate  supply,  not  less  than  two 
bottles,  basing  the  requisition  on  the  number  of  typhoid 
suspects,  etc.,  during  the  last  three  months.  As  the  bottles 
are  used,  additional  requisitions  should  be  submitted.  The 
blood  is  obtained  from  a  vein  at  the  bend  of  the  elbow  wdth  a 
large  sterile  syringe.  The  bottle  is  opened,  taking  care  not 
to  contaminate  it,  and  from  2  to  5  c.c.  of  blood  is  added  to 
the  bile.  The  bottle  is  sealed  with  paraffin  or  sealing  wax, 
wrapped  in  absorbent  cotton,  and  sent  in  an  approved 
mailing  case  to  the  nearest  department  laboratory,  with  a 
brief  history  of  the  case. 

Brion  and  Kayser  report  100  per  cent,  of  successful  blood 
cultures  during  the  first  week  of  typhoid;  others  report  84 
per  cent,  positive  during  first  week,  60  per  cent,  during  the 
second,  56  per  cent,  in  the  third,  and  48  per  cent,  in  the 
fourth  week.  The  period  of  election  for  blood  cultures  is 
between  the  second  and  fifth  days  of  the  disease,  and  for 
Widal  reactions,  the  second  week. 

At  the  present  time  blood  culture  is  the  only  satisfactory 
manner  of  estabhshing  the  diagnosis  of  paratyphoid  fever, 
which  cannot  be  differentiated  clinically  from  mild  typhoid. 
The  differential  diagnosis  by  agglutination  reactions  is  diffi- 
cult and  often  fails. 

The  bacilli  cannot  be  isolated  from  the  feces  unless  they  are 
present  constantly  and  in  fair  numbers,  which  is  rarely  the 
case  early  in  the  disease;  therefore  this  method  is  not  reUable 
for  early  diagnosis,  although  invaluable  for  the  detection  of 
bacillus  carriers.  This  leaves  blood  culture  as  the  method 
of  choice  in  the  diagnosis  of  continued  fevers. 


I  NOTES  ON  TRANSMISSIBLE  DISEASES  219 

It  is  now  desired  to  include  the  paratyphoid  fevers  in  the 
statistical  tables  of  the  annual  reports,  and  accurate  diagnosis, 
which  can  only  be  made  in  the  manner  above  described,  is 
essential  for  this  purpose. 

In  case  of  death,  small  pieces  of  spleen  should  be  placed  in 
bile  and  forwarded,  and  if  ulcers  or  swollen  Peyer's  patches 
are  found  in  the  intestines,  such  parts  should  be  forwarded  in 
lo  per  cent,  formalin. 

Geo.  H.  Torney, 

Surgeon-General,  U.  S.  Army. 

Approved: 

By  order  of  the  Secretary  of  War: 
Leonard  Wood, 

Major-General,  Chief  of  StafT. 

W.  D.,  Office  of  the  Surgeon-General,  Washington. 

Directions  for  Collecting  -Material  from  Typhoid 
Cases. 

I.  Diagnosis. — i.  By  Blood  Culture. — The  arm  is  washed 
with  hot  soap  and  water,  bichloride,  ether,  and  alcohol.  A 
hypodermic  syringe  is  boiled  in  i  per  cent,  sodium  carbonate 
solution,  with  the  piston  drawn  out  to  its  full  length  and  the 
barrel  filled  wdth  water ;  at  the  same  time  a  needle  of  medium 
caUber  and  a  pair  of  thumb  forceps  are  boiled.  When  all  is 
ready  a  tourniquet  is  placed  around  the  arm,  and  after  putting 
the  needle  on  the  syringe  with  the  thumb  forceps  it  is  plunged 
into  one  of  the  distended  veins  at  the  bend  of  the  elbow  and 
then  withdrawn  and  a  small  compress  is  bandaged  over  the 
wound.    Five  to  lo  c.c.  of  blood  is  put  into  the  ox-bile  medium. 

If  for  any  reason  the  use  of  a  syringe  is  impracticable,  blood 
may  be  obtained  from  the  ear  by  a  deep  puncture  made  with 
aseptic  precautions.  There  is  no  objection  to  squeezing  the 
ear  in  order  to  obtain  as  much  blood  as  possible. 

After  inoculation  and  before  mailing  the  bottle  should  be 
sealed  with  wax  or  paraffin. 


220  SANITATION  FOR  MEDICAL  OFFICERS 

2.  For  the  Widal  Reaction. — Blood  may  be  forwarded  in  a 
capillary  tube  of  large  caliber  or  in  a  small  bottlft  or  vial;  0.5 
c.c.  (8  drops)  should  be  sent.  A  short  sterile  vial  is  furnished. 
If  the  blood  is  taken  from  the  lobe  of  the  ear  it  should  be 
cleaned  and  rubbed  until  red  and  then  pricked  on  its  border 
with  a  bistoury  or  special  blood  lancet;  there  is  usually  no 
difficulty  in  obtaining  30  to  40  drops  by  squeezing  the  ear. 
Blood  may  be  collected  from  the  finger  by  w^inding  it  with  a 
handkerchief  or  piece  of  rubber  tubing  from  the  root  to  the 
distal  joint.  The  finger  should  be  sharply  flexed  and  pricked 
in  one  or  more  places  about  one-fourth  inch  above  the  root 
of  the  nail;  in  this  w^ay  10  drops  can  usually  be  obtained  and 
as  many  more  by  releasing  and  reapplying  the  tourniquet. 
If  the  bent  capillary  tube  (Wright's  capsule)  be  used,  the 
blood  should  run  in  by  gravity  through  the  curved  end;  the 
straight  end  is  then  sealed  in  the  flame,  and  after  the  expanded 
air  has  cooled,  creating  a  vacuum  w^hich  sucks  the  last  par- 
ticle of  blood  out  of  the  curved  end,  the  latter  is  also  sealed. 
The  bacilli  are  frequently  present  in  the  blood  clot  in  the 
earliest  days  of  the  disease,  and  may  be  cultivated  from  it 
even  when  the  Widal  is  still  negative. 

3.  If  dried  blood  be  furnished  a  Widal  can  be  made,  but 
no  cultivation  of  the  bacilli  from  the  clot  is  possible.  For 
this  and  other  reasons  fluid  blood  is  preferred. 

II.  To  Determine  when  it  is  Safe  to  Return  a  Patient 
TO  Duty. — The  first  sample  should  be  sent  when  convales- 
cence begins. 

I.  Feces. — ^A  small  sterile  bottle  provided  with  a  scoop 
is  furnished  for  the  collection  of  feces.  It  is  not  necessary 
to  fill  the  bottle,  since  it  is  possible  to  examine  not  more  than 
a  gram  or  two.  If  bottles  are  extemporized  they  should 
be  washed  out  with  boiUng  water  and  no  antiseptic  used. 
No  germicide  should  be  added  to  any  vessel  used  by  the^ 
patient  when  material  is  being  collected.  No  hexamethyl- 
enamin  or  similar  drug  should  be  given  to  the  patient  for 
twenty-Jour  hours  before  the  collection  of  samples. 


NOTES  ON  TRANSMISSIBLE  DISEASES  221 

2.  Urine  should  be  sent  in  the  long  vial,  i.  e.,  of  the  same 
size  as  the  one  furnished  for  feces. 

Not  less  than  three  sets  of  samples  should  be  examined  at 
intervals  of  three  days. 

III.  To  Determine  the  Source  of  Infection. — Samples 
of  urine  and  feces  may  be  sent  for  examination  from  people 
with  whom  the  patient  has  been  associated,  and  from  whom  he 
may  have  contracted  the  disease. 

All  material  for  examination  should  reach  the  laboratory 
in  as  fresh  a  condition  as  possible. 

The  postal  regulations  permit  the  sending  of  moist  speci- 
mens of  pathological  material  when  the  bottles  are  enclosed 
in  two  water-tight  tin  cans.  Care  must  be  taken  to  see  that 
the  washers  are  inserted  in  each  can  and  that  the  tops  are 
screwed  on  properly. 

1.  Packages  of  two  sorts  will  be  furnished:  (i)  for  the 
collection  of  feces,  urine,  and  blood,  and  (2)  bile  media  for 
blood  cultures.  The  second  package  will  not  be  furnished 
unless  it  is  specifically  requested. 

2.  The  container  for  bile  media  is  a  small  bottle  of  brown 
glass  with  glass  stopper.  The  bottle  must  be  surrounded 
with  sufiicient  absorbent  cotton  to  take  up  all  the  fluid  in 
case  the  bottle  breaks. 

The  threads  of  the  screw-top  maiUng  cases  are  occasionally 
jammed  in  the  mail,  and  when  this  happens  the  can  may  be 
opened  by  holding  the  cap  with  an  encircling  piece  of  heavy 
wire. 

Requests  for  containers  should  be  addressed  to  the  nearest 
Department  Laboratory. 

THE  VENEREAL  DISEASES;  SYPHILIS. 

Etiology. — Treponema  pallidum. 

Method  of  Transmission. — From  90  to  95  per  cent,  of 
infections  are  the  direct  result  of  sexual  intercourse  with 
infected    persons.      The    remaining    cases    of    extragenital 


222  SANITATION  FOR  MEDICAL  OFFICERS 

infection  are  indicated  by  extragenital  chancres,  of  which 
chancres  of  the  lips  and  mouth  are  the  most  frequent.  These 
extragenital  infections  are  caused  by  direct  or  indirect 
contact  with  infected  persons,  usually  by  means  of  kissing 
or  the  introduction  into  the  mouth  of  objects  recently  used 
by  syphilitics,  such  as  cups,  pipes,  etc.  The  Treponema 
pallidum  cannot  live  long  outside  the  body,  and  when  de- 
posited upon  external  objects  with  saliva  or  other  secretions 
from  infected  persons  the  organisms  die  as  soon  as  the 
secretions  dry.  Therefore  such  accidental  infections  must 
be  due  to  contact  with  infectious  material  that  has  only  left 
the  body  very  recently. 

Period  of  Incubation. — Clinical  observations  have  placed 
the  incubation  period  at  fifteen  days  for  the  minimum  and 
forty-two  days  for  the  maximum,  with  an  average  of  about 
twenty-five  days.  Animal  inoculations  indicate  an  average 
incubation  period  of  thirty-eight  days  with  a  maximum  of 
sixty  days.  The  longer  incubation  period  in  rabbits  is  prob- 
ably due  to  the  fact  that  they  are  not  as  susceptible  to  the 
disease  as  is  man. 

Prevalence  and  I^iportance  in  the  Military  Service. 
— The  prevalence  of  syphilis  varies  among  men  of  different 
classes,  ages,  and  races.  It  is  much  more  prevalent  among 
negroes  than  among  whites,  and  more  prevalent  among  older 
than  among  younger  men,  etc.  From  Wassermann  surveys 
it  may  be  estimated  that  from  5  to  20  per  cent,  of  males  are 
infected,  the  exact  percentage  depending  upon  the  circum- 
stances outlined  above.  As  the  course  of  the  disease  is  long 
with  a  great  tendency  to  relapses  it  causes  much  disability  in 
the  army,  and  as  it  is  often  unrecognized,  many  cases  on  the 
sick  report  masquerading  under  other  diagnoses  are  in  reality 
syphilis.  It  is  therefore  most  important  that  an  earnest 
endeavor  be  made  to  reduce  this  infection  to  a  minimum. 

Prophylaxis  and  Control. — The  disease  can  be  con- 
trolled in  the  military  services  if  commanding  officers  and 


I 


NOTES  ON  TRANSMISSIBLE  DISEASES  223 


surgeons  will  cooperate  efficiently  in  carrying  out  the  follow- 
ing measures :  A  high  venereal  rate  is  evidence  that  sufficient 
attention  is  not  being  paid  to  this  important  subject.  The 
measures  to  be  taken  may  be  classified  as  follows: 

I.  Early  Diagnosis  and  Treatment  of  Existing  Cases. — If 
treatment  is  efficient,  the  existing  cases  will  not  transmit  their 
infection  to  other  soldiers  (extragenital  infections)  or  to 
women  who  in  turn  may  infect  other  soldiers. 

1.  In  time  of  peace  a  Wassermann  test  on  all  recruits, all 
double-plus  cases  to  be  followed  and  treated  if  necessary  by 
the  surgeon  to  prevent  infection  and  to  keep  them  well  and 
performing  duty. 

2.  Early  diagnosis  of  cases  that  develop  in  the  command. 

(a)  Education  of  soldiers  to  report  all  cases  of  venereal 
disease  as  soon  as  noticed. 

(b)  Venereal  inspections  to  detect  concealed  cases.  (See 
G.  O.  No.  17,  W.  D.,  1912,  included  in  notes  on  Venereal 
Prophylaxis.) 

(c)  Use  of  modern  diagnostic  methods.  This  includes  the 
use  of  the  dark  field  and  special  stains  to  diagnose  syphilis 
in  the  primary  stage  when  a  cure  may  usually  be  obtained 
with  proper  treatment,  and  the  use  and  correct  interpreta- 
tion of  the  Wassermann  reaction.  Wassermann  reactions 
may  be  obtained  by  sending  the  blood  to  the  nearest  depart- 
ment laboratory. 

(d)  Efficient  treatment.  (See  Circular  No.  14,  W.  D.,  1914.) 

(e)  Isolation  in  hospital  during  the  time  when  he  could 
transmit  the  infection  to  others. 

(/)  Each  case  to  be  followed  with  a  syphilitic  register 
(Form  78,  Med.  Dept.),  so  that  the  case  will  not  escape 
from  observation  and  treatment  until  cured  or  separated 
from  the  service. 

II.  The  Prevention  of  New  Infections. 

I .  So  far  as  possible  the  men  should  be  educated  to  abstain 
from  intercourse. 


224  SANITATION  FOR  MEDICAL  OFFICERS 

2.  Venereal  Prophylaxis. — (Confidential  Circular  to  Medi- 
cal Officers.  See  Venereal  Prophylaxis.) — If  properly 
administered  promptly  after  exposure,  this  will  prevent  most 
infections.  Surgeons  should  personally  supervise  this  method 
to  ensure  that  it  is  administered  efficiently,  and  to  see  that 
men  who  ex-pose  themselves  are  actually  taking  the  treatment 
or  are  punished  for  their  breach  of  discipline. 

3.  Veneneal  Inspections. — (G.  O.  17,  W.  D.,  191 2.) 

4.  Punishment  of  those  who  develop  venereal  disease  with- 
out taking  the  prophylactic.  (Par.  2,  G.  O.  17,  W.  D.,  191 2, 
punishment  by  court-martial,  and  G.  O.  31,  W.  D.,  191 2,  and 
par.  I,  G.  O.  13,  W.  D.,  1913,  with  regard  to  stoppage  of  pay.) 

III.  General  Measures  to  Avoid  Contact  Injection. — (See 
Overcrowding  and  Contact  Infection.) 

IV.  Education. — To  be  conducted  by  company  com- 
manders and  medical  officers  by  means  of  lectures  and 
informal  talks,  circulars,  etc.,  containing  information  as  to 
the  nature  of  venereal  diseases,  the  danger  of  contracting 
them  and  methods  of  avoiding  them,  emphasizing  the  neces- 
sity of  continence  and  taking  particular  care  that  every  man 
knows  the  orders  with  regard  to  venereal  prophylaxis. 

Circular  No.  14,  W.  D.,  office  of  the  Surgeon-General, 
Washington,  August  3,  1914,  will  shortly  be  modified  as 
follows : 

Arsphenamine  is  indicated  (i)  for  the  rapid  control  of  the 
manifestations  of  syphilis,  both  clinical  and  serological.  For 
this  purpose  one  or  more  intravenous  injections  of  the  drug 
are  to  be  given,  the  dose,  interval  and  number  of  injections 
to  be  determined  by  the  indications  presented  in  each  indi- 
vidual case.  It  should  be  recognized  that  the  object  of  this 
treatment  is  to  secure  prompt  amelioration  of  the  symptorns 
only,  and  that  further  treatment  will  be  necessary  to  attain 
more  permanent  results.  (2)  For  the  radical  cure  of  syphilis 
in  the  primary  or  early  secondary  stages,  in  combination  with 
extensive  courses  of  treatment  with  mercury.     The  possi- 


I 


NOTES  ON  TRANSMISSIBLE  DISEASES  225 

bility  of  obtaining  such  a  cure  is  now  well  established.  The 
highest  percentage  of  successful  results  is  obtained  in  cases 
treated  in  the  primary  stage  before  the  appearance  of  a  posi- 
tive Wassermann  reaction;  in  such  cases  the  diagnosis  must 
necessarily  rest  upon  discovery  of  the  parasite  in  the  initial 
lesion.  The  combined  treatment  consists  of  from  five  to 
eight  intravenous  injections  of  one  of  the  arsphenamine 
preparations  at  intervals  of  from  one  to  two  weeks,  combined 
with  an  intensive  course  of  mercurial  treatment  by  inunction 
or  intramuscular  injection.  The  administration  of  mercury 
should  be  pushed  until  the  physiological  limit  is  reached. 
This  should  begin  at  the  same  time  or  within  a  few  days  of 
the  first  dose  of  arsphenamine,  and  a  course  of  mercury 
should  consist  of  three  or  four  weekly  injections  of  a  soluble 
salt  or  two  injections  of  an  insoluble  salt,  or  thirty-five  to 
forty-five  daily  inunctions  of  mercurial  ointment. 

Only  patients  in  good  health  in  other  respects  and  whose 
kidneys  are  known  to  be  normal  are  suitable  for  this  intensive 
treatment.  It  is  directed  that  in  all  cases  in  which  it  is  con- 
templated to  administer  arsphenamine,  the  urine  of  the 
patient  should  be  examined,  and  should  any  case  show  kidney 
involvement,  that  these  drugs  be  withheld  or  used  in  small 
doses. 

A  urinary  examination  will  also  be  made  after  each  admin- 
istration of  arsphenamine. 

Contra-indications. — Aside  from  the  ordinary  contra- 
indications, such  as  severe  organic  disease  due  to  other 
causes,  two  possible  complications  must  be  kept  in  mind — 
nervous  relapse  and  secondary  reactions.  Nervous  relapse 
may  occur  after  inadequate  treatment  in  cases  in  which  the 
nervous  system  is  already  infected.  In  such  cases  one  or  two 
injections  of  arsphenamine,  not  followed  up  by  other  treat- 
ment, may  do  more  harm  than  good;  and  to  prevent  this  a 
thorough  combined  course  of  treatnient  should  be  instituted, 
or  mercury  alone  used. 
15 


226  SANITATION  FOR  MEDICAL  OFFICERS 

Secondary  Reactions. — Recent  literature  and  army  expe- 
rience record  a  number  of  deaths  following  the  administration 
of  arsphenamine.  Most  of  the  deaths  present  identical 
symptoms;  they  occur  several  days  after  the  injection  of 
arsphenamine,  and  they  do  not  follow  the  first  injection  of 
the  drug,  but  one  of  the  later  injections  of  a  series.  In  order 
to  understand  the  mechanism  of  these  reactions  and  the  means 
to  be  taken  to  prevent  them,  a  brief  consideration  of  the 
action  of  arsphenamine  in  the  body  is  necessary. 

Action  of  Arsphenamine  in  the  Body. — Arsphenamine  (dioxy- 
diaminoarsenobenzol)  is  a  compound  insoluble  in  w^ater. 
It  is  soluble  as  a  dihydrochloride  (the  powder  as  sold  in 
ampuls)  or  as  a  di-sodium  compound  (formed  after  neutrali 
zation  with  NaOH).  In  either  of  these  forms  arsphenamine 
is  an  eminently  unstable  compound,  and  it  is  capable  of 
uniting  with  all  sorts  of  substances  with  which  it  comes  in 
contact. 

A  short  time  after  the  di-sodium  solution  of  arsphenamine 
is  injected  in  a  vein  this  compound  loses  its  sodium.  Some 
of  the  sodium  combines  with  the  free  carbonic  acid,  forming 
sodium  bicarbonate  and  reprecipitating  the  arsphenamine. 
Another  part  of  the  arsphenamine  which  remains  as  a  mono- 
or  di-sodium  salt  combines  with  the  calcium  phosphate  of 
the  blood.  Deprived  of  the  sodium,  the  arsphenamine  is  once 
more  insoluble  and  is  all  precipitated  in  the  blood  stream.  The 
presence  of  free  oxygen  and  the  sodium  chloride  of  the  blood 
hastens  this  precipitation.  A  Uttle  later  the  organic  bases 
contained  in  the  plasma  unite  with  this  precipitated  arsphena- 
mine forming  new  soluble  compounds.  This  transformation 
into  new  soluble  compounds  requires  some  hours,  after  which 
these  compounds  are  excreted  by  the  urine,  so  that  they  are 
all  excreted  in  normal  cases  in  forty-eight  hours. 

A  dose  of  arsphenamine  which  is  well  borne  w^hen  given 
slowly  for  fifteen  minutes  in  dilute  solution  will  be  surely 
fatal  when  injected  in  one  minute  in  concentrated  solution. 


I 


NOTES  ON  TRANSMISSIBLE  DISEASES  227 

In  animals  so  killed,  masses  of  the  precipitated  arsphenamine 
are  found  in  the  walls  of  the  heart,  the  lungs,  central  nervous 
system  and  other  organs,  so  that  it  is  evident  that  deaths 
occurring  immediately  after  the  injection  of  arsphenamine, 
as  well  as  many  of  the  severe  reactions  following  immediately 
after  the  administration  of  this  drug,  are  due  to  the  emboli 
formed  iA  the  different  organs  by  the  precipitate.  These 
so-called  primary  reactions  are  mechanical  and  have  nothing 
whatever  to  do  with  the  toxicity  properly  speaking  of  the  ' 
product.  The  symptoms  of  this  embolism  depend  somew^hat 
upon  the  locations  affected,  but  in  general  include  nausea 
and  vomiting,  headache  and  later  fever  and  even  epilepti- 
form convulsions,  coma  and  death.  Necropsy  shows  in  all 
these  cases  an  intense  congestion  of  all  the  viscera  and  inter- 
stitial hemorrhages.  As  generally  administered,  death  is 
very  rare  after  these  primary  reactions,  which  may,  however, 
be  very  alarming. 

On  the  other  hand  death  is  common  after  the  so-called 
secondary  reactions,  which  appear  only  from  three  to  five 
days  after  the  administration  of  the  drug.  The  symptoms 
and  necropsy  findings  of  the  secondary  reactions  are  prac- 
tically identical  with  those  of  the  primary  reactions.  Since 
these  secondary  reactions  practically  never  follow  the  first 
injection  of  arsphenamine,  it  has  been  suggested  that  they 
are  caused  by  a  certain  intolerance  w^hich  develops,  as  a 
result  of  w^hich  the  bases  normally  present  in  the  blood,  and 
which  are  capable  of  forming  soluble  products  with  arsphena- 
mine, are  not  formed  in  sufficient  quantity,  and  therefore 
the  precipitated  arsphenamine  does  not  redissolve.  The 
emboli  then  formed  are  permanent  and  the  symptoms  and 
lesions  produced  are  much  more  severe  than  in  the  primary 
reactions,  where  the  precipitate  is  soon  dissolved.  These 
considerations  which  are  based  on  much  experimental  evi- 
dence, indicate  that  in  the  administration  of  arsphenamine 
the  following  precautions  should  be  taken: 


228  SANITATION  FOR  MEDICAL  OFFICERS 

Precautions. — i.  Be  sure  the  arsphenamine  is  thoroughly 
dissolved  after  neutralizing.  Any  undissolved  particles  are 
converted  by  the  alkali  into  a  product  that  is  practically 
insoluble. 

2.  Neutralization. — Each  loo  milligrams  of  arsphenamine 
requires  theoretically  0.85  c.c.  of  normal  sodium  hydroxide 
to  convert  it  into  the  di-sodium  salt.  Less  than  this  amount 
will  frequently  suffice  to  redissolve  the  precipitate,  since  the 
mono-sodium  salt  is  also  soluble.  If  less  than  0.85  c.c.  normal 
or  4  per  cent.  NaOH  per  100  mg.  is  used,  part  of  the  arsphena- 
mine will  go  into  solution  as  a  mono-sodium  salt.  This  is  to 
be  avoided,  and  a  slight  excess  of  alkali  is  even  beneficial, 
since  the  precipitation  of  the  arsphenamine  in  the  circulation 
is  delayed  by  the  use  of  slight  excess  of  alkali.  It  is  recom- 
mended, therefore,  that  in  preparing  arsphenamine,  0.9  c.c. 
of  normal  or  4  per  cent.  NaOH  be  added  for  each  100  mg.  of 
the  drug.  This  would  be  5.4  c.c.  for  each  0.6  gram.  A  great 
excess  of  alkali  is  liable  to  cause  thrombosis.  A  great  excess 
should  therefore  be  avoided,  and  the  tendency  to  injury  of 
the  vein  caused  by  the  slight  excess  of  alkali  used  is  overcome 
by  giving  the  injection  in  dilute  solution. 

3.  Give  the  injection  in  dilute  solution.  It  is  not  believed 
that  less  than  150  c.c.  should  be  used  to  0.6  gram  of  arsphena- 
mine, and  injections  of  200  to  250  c.c.  are  well  borne.  The 
injection  of  a  dilute  solution  slowly,  minimizes  the  dangers 
of  too  sudden  precipitation  of  the  drug  in  the  blood  stream 
and  reduces  the  liability  of  subsequent  reactions  to  a  mini- 
mum. Fifteen  to  twenty  minutes  should  be  consumed  in 
giving  the  injection. 

General  Directions. — Arsphenamine  is  put  in  sealed  ampuls 
filled  with  a  neutral  gas,  or  in  vacuo  to  prevent  oxidation. 
The  ampul  before  opening  should  be  immersed  in  95  per  cent, 
alcohol  for  a  few  minutes  to  detect  any  crack  in  the  glass. 
The  arsphenamine  should  be  dissolved  immediately  after 
opening  the  ampul.     Cold  water  only  should  be  used,  since 


NOTES  ON  TRANSMISSIBLE  DISEASES  229 

hot  water  is  unnecessary  and  increases  the  toxicity  of  the 
drug.  (The  exception  to  this  rule  is  Arsenobenzol,  Dermato- 
logical  Research  Laboratory,  which  is  soluble  with  difficulty 
in  cold  water  and  in  dissolving  which  hot  water  may  be  used.) 
Only  freshly  distilled  water,  sterilized  immediately  and  kept 
well  stoppered,  should  be  used.  Salt  solution  made  of  stale 
distilled  water  contains  many  dead  organisms  after  steriliza- 
tion, and  the  injection  of  this  bacterial  proteid  into  the  cir- 
culation is  one  cause  of  febrile  reactions.  The  solution  is  then 
neutralized  in  accordance  with  directions  given  above,  care 
being  exercised  to  use  a  solution  of  sodium  hydroxide  free 
from  sodium  carbonate.  When  sodium  hydroxide  has  stood 
for  some  time  sodium  carbonate  is  formed  from  the  carbon 
dioxide  of  the  air,  so  that  unless  special  precautions  are  taken 
to  prevent  this,  the  sodium  hydroxide  solution  should  be 
freshly  prepared. 

Intravenous  Injections. — These  are  easily  given  with  the 
standard  apparatus,  which  should  contain  a  light  plug  of 
absorbent  cotton  in  the  neck  to  filter  out  undissolved  par- 
ticles. The  injection  tube  and  needle  should  be  filled  with 
salt  solution  before  the  prepared  solution  is  poured  into  the 
reservoir,  so  that  salt  solution  only  will  escape  into  the  tissues 
if  the  vein  is  missed  on  the  first  trial.  In  most  cases  it  is 
unnecessary  to  expose  a  vein  by  an  incision,  which  is  justi- 
fiable only  when  absolutely  necessary.  Every  piece  of  appa- 
ratus used  should  be  scrupulously  clean  and  sterile.  Use  acid 
cured  or  especially  prepared  rubber  tubing  to  avoid  the 
sulphur  bloom  which  forms  on  common  rubber. 

Neoarsphcnamine  versus  Arsphenamine.  —  Neoarsphena- 
mine  dissolves  readily  in  water  and  forms  a  neutral  solution 
ready  for  use.  This  facility  of  preparation  should  not  lead 
to  a  preference  for  neoarsphcnamine.  The  latter  is  much 
more  unstable  than  arsphenamine,  and  the  toxicity  of  a 
solution  of  neoarsphcnamine  is  increased  two  and  one-half 
times  after  exposure  of  one-half  hour  to  the  air.    This  change 


230  SANITATION  FOR  MEDICAL  OFFICERS 

is  SO  serious  that  in  testing  preparations  of  neoarsphenamine 
it  is  necessary  to  keep  the  drug  at  io°  C.  during  the  test  to 
prevent  this  deterioration.  In  addition  cHnicians  are  fairly 
agreed  that  arsphenamine  is  clinically  more  effective  in  pro- 
portionate doses  than  neoarsphenamine.  The  administration 
of  these  preparations  is  not  to  be  undertaken  carelessly,  and 
it  is  believed  that  any  physician  who  is  prepared  to  give 
neoarsphenamine  under  proper  conditions,  is  also  prepared  to 
go  to  the  slight  additional  work  of  neutralizing  arsphenamine. 

Attention  is  Called  to  the  Following  Recommenda- 
tions Concerning  the  Handling  of  Syphilis. 

Plan  oe  Treatment. — i.  It  is  of  the  highest  importance 
for  the  cure  of  syphilis  that  the  initial  lesion  of  syphilis  be 
recognized  at  the  earliest  possible  moment.    To  that  end: 

(a)  Any  excoriation,  papule,  nodule,  crack,  "hair  cut," 
herpetic  or  other  erosions,  no  matter  how  small,  as  well  as 
ulcers  about  the  genitals— and  elsewhere  if  there  is  any 
reason  to  suspect  them — should  immediately,  before  treatment, 
be  sent  for  examination  for  Spirocheta  pallida  either  to  the 
venereal  infirmary  or  the  base  hospital. 

(b)  Any  lesion  which  may  be  a  chancre  should  not  be 
treated  with  antiseptics,  particularly  with  mercurials,  or 
cauterized  chemically  or  with  heat,  before  examination  for 
spirocheta. 

2.  Chancroids  should  be  suspected  of  syphilis  until  repeated 
examinations  for  spirochetal,  repeated  Wassermanns,  and 
until  sufficient  time  has  elapsed  for  the  failure  of  the  appear- 
ance of  secondaries  to  show  that  syj^hilitic  infection  does  not 
exist. 

3.  No  case  should  be  treated  for  early  syphilis  until  a 
positive  diagnosis  is  made  either  by  demonstration  of  the 
Spirocheta  pallida  or  by  positive  Wassermann  reaction. 

4.  Chancres,  chancroids  and  all  secondary  cases  of  syi^hilis 


NOTES  ON  TRANSMISSIBLE  DISEASES  231 

should  be  sent  to  the  base  hospital  and  kept  there  until  open 
lesions  have  healed. 

5.  Upon  discharge  of  a  syphilitic  patient  from  the  base 
hospital,  syphilitic  register  should  go  to  the  soldier's  organiza- 
tion with  him;  receipt  for  syphilitic  register  should  be  returned 
to  the  base  hospital. 

Early  Treatment. — Arsphenamine. 

(a)  Preparation  of  the  patient: 

tjse  cautiously  in  patients  with  lesions  of  heart  or  blood- 
vessels, kidneys  or  other  viscera. 

Examine  urine  for  albumin  before  each  administration. 

Administer  drug  on  empty  stomach. 

No  breakfast  or  dinner,  if  given  in  morning;  no  dinner  or 
supper,  if  given  in  afternoon. 

(b)  Administration  of  arsphenamine: 
Each  course  to  consist  of  6  doses. 
Administer  at  intervals  6i  five  to  seven  days. 

Dosage  to  be  on  the  basis  of  i  decigram  to  approximately 
each  30  pounds  body  weight;  first  dose  to  be  one-half  of 
normal  dose,  that  is:  first  dose  to  be  2  to  3  dcgm.;  subse- 
quent doses  4  to  6  dcgm. 

Dilution  to  be  not  less  than  25  c.c.  water  for  each  o.i  of 
arsphenamine.  (Technic  of  preparation  of  solution.  Red 
Book,  page  23.  If  the  brand  salvarsan  is  used,  do  not  use 
hot  water.) 

Administer  by  gravity  method  and  inject  slowly.  (Technic 
of  injection,  Red  Book,  page  24.) 

After-care:  Require  rest,  preferably  in  bed,  until  next 
morning. 

Mercury. — Administer  mercury  in  the  form  of  injections 
of  bichloride  or  of  some  of  the  equivalent  soluble  salts;  or, 
if  this  is  impracticable,  use  injections  of  salicylate  or  calomel 
or  gray  oil.    (Red  Book,  page  29.) 

Normal  dose  of  bichloride  is  0.016  gram  (0.25  grain)  every 
second  day;  administer  in  a  solution  containing  i  per  cent. 


232  SANITATION  FOR  MEDICAL  OFFICERS 

bichloride  and  i  per  cent,  sodium  chloride,  25  minims  equal 
0.016  gram  (0.25  grain).    (Red  Book,  page  30.) 

Normal  dose  of  salicylate  is  0.064  gram  (i  grain)  normal 
dose  of  mercury  in  the  form  of  gray  oil  or  calomel  is  0.064 
gram  (i  grain)  given  in  a  suspension  of  10  per  cent,  to  20 
per  cent,  in  oil;  that  is,  5  drops  of  20  per  cent,  suspension  or  10 
drops  of  10  per  cent,  suspension  is  the  normal  dose  of  0.064 
gram  (i  grain).     (Red  Book,  page  29.) 

The  dose  of  any  of  the  salts  may  be  increased  with  caution. 

Inject  soluble  salts  into  the  subcutaneous  fat  of  the  but- 
tocks or  into  the  gluteal  muscle — not  into  the  skin.  Inject 
insoluble  salts  into  the  gluteal  muscle.    (Red  Book,  page  30.) 

For  care  of  patients  while  taking  mercury  or  when  salivated, 
see  Red  Book,  page  32. 

A  course  of  mercury  treatment  should  extend  over  from 
eight  to  ten  weeks,  in  which  time  the  patient  should  receive 
twenty-four  to  thirty  injections  of  a  soluble  salt  or  nine  to 
ten  injections  of  insoluble  salt. 

After  the  first  course  of  arsphenamine  and  mercury  give 
the  patient  one  month's  rest. 

At  the  end  of  one  month  take  Wassermann ;  if  Wassermann 
is  positive,  repeat  the  complete  course;  if  Wassermann  is 
negative,  repeat  only  the  course  of  mercury. 

At  the  end  of  second  course,  rest  two  months;  then  give 
third  course  in  accordance  with  the  Wassermann  conditions 
as  outlined  in  second. 

Three  such  courses  with  these  intervals  of  rest  carry  the 
patient  through  the  first  ten  months  of  treatment. 

During  the  second  year,  if  Wassermann  remains  positive, 
repeat  complete  courses  of  treatment  with  intervals  of  rest 
of  two  months  between. 

During  second  year,  if  Wassermann  is  negative ,  give 
two  courses  of  mercury  with  intervals  of  four  months 
between. 

The  scheme  of  treatment  outlined  above  is  as  follows: 


NOTES  ON  TRANSMISSIBLE  DISEASES  233 

First  Year. 

First  course  of  treatment 2  to  2 1  months 

j^gg^  I    month 

Second  course  of  treatment 2  to  2 1  months 

j^gg^  2    months 

Third  course  of  treatment 2  to  2|  months 

Second  Year. 

(If  Wassermann  is  negative.) 

Rest  after  third  course 4  months 

Course  of  mercury 2  months 

Rest 4  months 

Course  of  mercury 2  months 

Second  Year. 
(If  Wassermann  ^is  positive.) 

If  Wassermann  remains  positive,  complete  courses  of 
treatment  should  be  given  with  intervals  of  rest  of  two 
months  each. 

Treatment  of  Late  Syphilitic  Lesions. — These  are  to 
be  treated  by  one  or  more  courses  of  mercury  and  arsphena- 
mine  given  in  the  same  way  as  indicated  for  early  S3.philis. 
The  use  of  mercury  and  arsphenamine  in  late  lesions  should 
be  combined  with  that  of  iodides.  Iodides  should  be  adminis- 
tered in  a  solution  containing  i  gram  (15  grains)  of  sodium  or 
potassium  iodide  to  i  c.c.  of  water.  Dose  to  consist  of  10 
to  100  drops;  that  is,  0.5  to  6  grams  (7.5  to  90  grains)  t.  i.  d., 
given  in  large  glass  of  water.  Only  in  nervous  lesions  are 
large  doses  of  iodides  required,  i  to  3  grams  (15  to  45  grains) 
t.  i.  d.  are  sufficient  for  most  other  lesions  of  S3^hilis. 

All  of  the  above  treatment  except  the  first  few  weeks — 
one  to  three  weeks — while  he  is  in  the  hospital,  can  be  given 
while  the  patient  is  doing  duty,  and  should  be  so  done  unless 
there  are  unusal  contra-indications. 

The  patient  with  early  syphilis  should  be  kept  in  the  base 
hospital  until  his  chancre  and  other  open  lesions  are  healed; 
that  is,  from  one  to  three  or  four  wTeks.    After  this  he  should 


234  SANITATION  FOR  MEDICAL  OFFICERS 

be  transferred  to  the  venereal  unit  in  the  developmental 
battalion  or  depot  brigade.  After  the  completion  of  his  first 
course  of  treatment,  unless  there  are  unusual  circumstances 
in  his  case,  he  can  be  put  on  full  duty  with  his  organization. 
When  he  is  returned  to  his  organization  his  syphilitic  register 
must  be  sent  to  his  organization  on  the  same  day. 

Syphilitic  Registers. — The  information  contained  in  well- 
kept  syphilitic  registers  has  been  found  to  be  of  great  scientific 
and  practical  value.  It  is  enjoined  that  every  elTort  be  made 
to  follow  cases  closely,  to  record  important  data,  and  to  for- 
ward the  register  to  the  proper  authority  whenever  the  patient 
is  transferred,  in  order  that  the  patient  may  be  continuously 
under  treatment  until  he  is  cured  or  separated  from  the 
service. 

W.    C.    GOEGAS, 

Surgeon-General,  United  States  Army. 

GONORRHEA. 

Etiology. — Diplococcus  Gonorrheas  or  Gonococcus. 

Method  of  Transmission. — Gonorrheal  ophthalmia  may  be 
conveyed  by  the  use  of  towels  soiled  with  gonorrheal  dis- 
charges and  by  other  methods  of  indirect  contact.  Urethral 
gonorrhea  in  adult  males  is  always  acquired  as  the  result  of 
sexual  intercourse  with  an  infected  individual. 

Period  of  Incubation. — ^The  incubation  period  averages 
two  to  five  days,  but  may  be  as  long  as  two  or  three  weeks. 

Prophylaxis  and  Control. — There  is  very  definite  experi- 
mental and  clinical  evidence  indicating  that  the  injection  of 
various  silver  salts  into  the  urethra  following  intercourse 
will  prevent  the  disease.  The  measures  to  be  taken  may  be 
summed  up  as  follows: 

1.  Continence. 

2.  Venereal  prophylaxis.     (See  Venereal  Prophylaxis.) 

3.  Venereal  inspections  to  detect  concealed  cases. 

4.  Punishment  of  those  who  develop  gonorrhea  without 


NOTES  ON  TRANSMISSIBLE  DISEASES  235 

taking  the  prophylactic.     (G.  O.  17,  W.  D.,  1912,  G.  0.  31, 
W.  D.,  1912,  G.  O.  13,  W.  D.,  1913.) 

5.  Efficient  treatment  of  all  cases  reporting  or  detected 
in  order  that  they  may  not  continue  as  sources  of  infection. 

6.  Methods  to  avoid  contact  infection.  (For  prevention  of 
Gonorrheal  Ophthalmia.) 

CHANCROID. 

Etiology. — Bacillus  of  Ducrey. 

Method  of  Transmission. — ^Always  by  sexual  intercourse 
with  an  infected  individual,  although  it  must  be  remembered 
that  the  sores  are  auto-inoculable,  so  that  when  the  infection 
is  once  acquired,  sores  may  continue  to*  develop. 

Period  of  Incubation. — Generally  one  to  five  days.  In 
an  experimental  inoculation  of  a  macacus  monkey,  a  pustule 
developed  in  forty-eight  hours  and  an  ulcer  developed  on  the 
third  day  having  all  the  characteristics  of  a  soft  chancre  and 
containing  the  bacillus  of  Ducrey. 

Prophylaxis  and  Control. — ^The  washing  described  in 
the  circular  outlining  the  method  of  venereal  prophylaxis, 
and  the  use  of  the  calomel  ointment  will  undoubtedly  prevent 
the  great  majority  of  these  infections.  Other  methods  are  the 
same  as  for  gonorrhea  and  syphilis. 

This  is  purely  a  local  disease  and  never  gives  rise  to  con- 
stitutional symptoms  as  does  syphilis,  but  it  causes  a  great 
deal  of  disability  and  inefficiency  among  soldiers,  owing  to 
the  tendency  for  the  organisms  to  be  taken  up  by  the  lymph- 
atics, thus  causing  the  characteristic  suppurating  inguinal 
buboes  which  may  incapacitate  a  man  for  weeks  or  months. 

The  three  venereal  diseases  just  outlined  cause  more  ad- 
missions to  sick  report  and  disability  than  any  other  class 
of  diseases. 

EPIDEMIC  JAUNDICE  (WEIL'S  DISEASE). 

Epidemic  jaundice  has  been  rather  common  among  soldiers 
in  the  trenches  in  Europe  as  well  as  in  other  parts  of  the  world. 


1 


236  SANITATION  FOR  MEDICAL  OFFICERS 

Etiology. — Spirocheta  icterohemorrhagica.  This  organ- 
ism may  be  found  in  the  blood  and  also  in  the  urine  from  cases 
of  the  disease.  It  has  also  been  found  in  the  kidneys  of  rats 
and  field  mice,  and  these "  animals  may  serve  as  the  usual 
carriers  of  the  infection.  Morphologically  it  resembles  the 
spirochetes  of  relapsing  fever.  It  is  pathogenic  for  guinea-pigs. 

Method  of  Transmission. — After  the  thirteenth  day  of  the 
disease  the  organism  may  be  found  in  the  urine  until  at  least 
the  thirtieth  day.  Experiments  have  indicated  that  the 
organism  is  able  to  penetrate  the  unbroken  skin,  and  that  it  is 
able  to  live  in  the  water  for  some  time.  Therefore  it  seems 
probable  that  when  the  water  in  the  trenches  becomes  con- 
taminated with  the  urine  of  soldiers  who  suffer  or  have 
suffered  with  this  disease,  other  soldiers  standing  in  this  w^ater 
may  contract  the  infection. 

Incubation  Period. — Inada  {Jour.  Exper.  Med.,  191 7,  xxvi, 
359)  states  that  the  period  of  incubation  varies  from  five  to 
seven  days  in  skin  infections.  It  is  rarely  so  long  as  thirteen 
days. 

Prophylaxis. — Should  be  aimed  to  prevent  contamination 
of  the  trenches  with  infectious  urine  and  to  eradicate  rats 
and  mice. 

1.  Prompt  reporting  of  all  cases  of  the  disease.  Suspected 
cases  should  be  sent  to  the  rear  and  diagnosis  be  made  by 
stained  smears  of  the  blood  (Wright's  stain  may  be  used)  or 
by  injecting  the  blood  into  a  guinea-pig.  The  guinea-pig 
suffers  from  a  similar  disease  and  the  spirochetes  may  be 
found  in  its  blood  and  in  its  liver. 

2.  Isolation  of  cases  until  the  urine  is  free  from  spirochetes. 
This  isolation  need  not  be  complete,  but  the  man  should  be 
kept  out  of  the  trenches,  and  should  be  instructed  not  to 
urinate  except  in  a  water-closet  or  where  the  urine  may  be 
disinfected.  This  precaution  should  be  exercised  for  at  least 
six  weeks  from  the  beginning  of  the  disease. 

3.  The  provision  of  proper  #uiinals  in  the  trenches,  and 


NOTES  ON  TRANSMISSIBLE  DISEASES  237 

supervision  of  the  men  to  see  that  they  us-e  them  and  do  not 
urinate  elsewhere. 

4.  If  possible  pump  all  standing  water  out  of  the  trenches 
and  keep  them  dry.     (See  Sanitation  of  Trenches.) 

YELLOW  FEVER. 

Etiology. — ^A  filtrable  virus  at  present  unknown,  but  it 
may  be  destroyed  by  heating  to  55°  C.  for  ten  minutes. 

Method  of  Transmission. — ^The  disease  is  transmitted  only 
by  the  bite  of  the  Stegomyia  fasciata  (calopus).  The  blood  is 
infectious  only  during  the  first  three  days  of  the  fever,  so  that 
the  mosquito  must  bite  during  this  time  to  become  infected. 
The  organism  goes  through  a  cycle  of  development  in  the 
mosquito  which  lasts  from  twelve  to  fourteen  days,  and 
thereafter  the  mosquito  may  transmit  the  disease  to  anyone 
it  bites.  Mosquitoes  once  infected  can  transmit  the  disease 
for  the  rest  of  their  life  which  averages  about  one  hundred 
and  fifty  days. 

Incubation  Period. — Calculated  from  experimental 
mosquito  bites  it  varies  from  two  days  and  twenty-two 
hours  to  seven  days  and  five  hours.  The  average  period  is 
from  three  to  six  days.  The  period  of  development  in  the 
mosquito  plus  the  incubation  period  is  from  fifteen  to  eighteen 
days,  which  is  the  time  that  must  elapse  after  the  introduction 
of  a  case  of  yellow  fever  before  the  appearance  of  a  secondary 
case. 

Quarantine. — Based  on  the  information  from  experi- 
mental bites  it  would  be  supposed  that  the  quarantine  period 
would  have  to  be  seven  days  in  order  to  be  absolutely  safe. 
The  official  quarantine  regulations,  however,  call  for  six  days, 
and  so  far  as  known  no  case  has  developed  after  having  been 
detained  for  this  period. 

Control. — Sanitary  measures  are  all  aimed  at  the  mos- 
quito and  may  be  divided  into  those  aimed  to  prevent  the 
possibility  of  mosquitoes  becoming  infected  from  existing 


238  SANITATION  FOR  MEDICAL  OFFICERS 

cases,  and  general  measures  aimed  at  reducing  the  total 
number  of  mosquitoes.  Gorgas  has  pointed  out  that  mos- 
quito extermination  is  not  necessary  to  eradicate  yellow  fever. 
If  their  numbers  are  much  reduced,  the  chain  of  infection  is 
sure  to  be  broken.  The  disease  is  much  easier  than  malaria 
to  eradicate,  largely  owing  to  the  fact  that  patients  are  only 
infective  during  the  first  three  days  instead  of  for  weeks  or 
months  as  in  the  case  of  malaria. 

I.  Elimination  of  Injected  Mosquitoes. 

1.  Early  notification  of  all  cases  of  the  disease. 

2.  Isolation  of  cases  and  suspected  cases  in  doubly  screened 
wards. 

3.  Similar  isolation  of  contacts  for  the  period  of  six  days. 

4.  Fumigation  of  rooms  occupied  by  patients  to  kill 
mosquitoes  that  may  have  bitten. 

5.  Obtain  history  from  patient  of  all  places  visited  and 
fumigate  them. 

II.  General  Measures. — Systematic  mosquito  destruction, 
including  all  measures  for  killing  both  larvae  and  adult 
mosquitoes  as  described  under  Mosquitoes.  It  must  be 
remembered,  however,  that  the  Stegomyia  is  a  peculiarl). 
domestic  mosquito  and  commonly  breeds  about  houses.  All 
water  cisterns  must  be  screened,  the  gutters  of  houses  cleaned, 
and  all  receptacles  that  can  hold  water,  such  as  empty  tin  cans 
water  bottles,  etc.,  must  be  collected  and  removed.  In 
fighting  any  particular  mosquito  a  study  of  the  habits  of  that 
species  must  be  most  carefully  studied. 

III.  Education. — This  may  be  conducted  by  means  of 
lectures,  pamphlets,  posters,  etc.  It  is  most  necessary  to 
secure  results  to  avoid  antagonizing  the  native  population 
who  are  the  source  of  the  infection  but  who  must  be  handled 
with  the  greatest  tact.  A  good  method  described  by  Gorgas 
is  a  system  of  fines  for  sanitary  lapses,  which,  however,  are 
remitted  providing  the  nuisance  is  abated. 


INDEX. 


A 

Absorption  pit,  kitchen  slops 61 

urine ^^^ 

Administration,  sanitary,  of  civil  territory 112 

Admission  rate 1^^ 

Alum  in  purification  of  water 92 

Antitoxin,  diphtheria 173,  175 

tetanus -^' 

Ants,  poison  for 1^0 

Arsphenamine,  action  of,  in  body 226 

contraindications 225 

indications 224 

method  of  administration 228 

B 

Bag,  water,  sterilizing 88 

Baits  for  fly  traps .      .      .      .  125 

Bath  house  for  delousing 103 

Bathing  after  trench  service 102 

Battlefield,  hygiene  of 108 

Bed-bugs,  eradication  of 150 

Bedding,  care  of 26 

Bernhardt's  formula  . 74 

Blisters  on  feet,  treatment  of 83 

Boiling  as  a  means  of  purification  of  water 93 

Bone  black  for  treatment  of  latrines 58 

Borax  to  prevent  fly  breeding 55 

C 

Calcium  hypochlorite  in  purification  of  water 89 

Caldwell  crematory 50 

(239) 


240  '        INDEX 

Camp  regulations 25 

site,  survey  of 23 

Cans,  garbage 53 

urine 27,  58 

Carbohydrates,  food  value  of 31,  40 

Carbon  dioxide,  test  for 64 

Care  of  feet 79 

Carriers,  cholera 168 

diphtheria 173 

dysentery 178 

malaria 183 

typhoid 216 

Chancroid 235 

Cholera 167 

vaccine 22,  169 

Citronella  oil 145 

Civil  sanitary  organization 112 

Civilian  employees,  smallpox  vaccination 14 

typhoid  vaccination 17 

Cleanliness,  personal 28,  168 

Clothing,  efifect  of  sterilization  on   .       .      .     • 135 

importance  of  sufficient 170 

Cockroaches 150 

Colds 170 

Contact  infection 61,  156 

Crematory,  rock-pile 49 

Creosote  oil 101,  109 

Crude  oil 53,  55,  58,  100 

Culex  fatigans  as  transmitter  of  dengue 171 

Cyanide  fumigation 151 


D 

Darnall  filter 92 

Dead  animals,  treatment  of 110 

burial  of 109 

Deficiency  diseases 42 

Delousing,  method  of 213 

Dengue 171 

Diet,  basal  requirements 31 

proteid  required 40 

Diphtheria 172 

Disinfection     ....,,,, 158 


INDEX  241 

Disposal  of  manure 53,  55 

Dysentery,  amebic 176 

treatment  of  carriers 178 

bacillary 179 

vaccine 22 


E 

Efficiency,  Pignet's  index  of 74 

Embarkation,  inspections  prior  to 96 

sanitary  orders  governing 95 

Epidemic  disease,  reports  of 152 

jaundice -..       =      ....  235 

Exercises  for  training 71 


P 

Fat,  food  value  of 31,  40 

separation  from  water 60 

Feces,  disposal  of,  in  trenches 98 

Feet,  care  of 79 

Filter,  Darnall 92 

Fireless  cookers  for  trenches 100 

Fleas 118 

Flies 121 

Fly  poisons 125 

traps 125 

Food  not  allowed  in  tents 26 

sale  of,  in  camps 28 

intrenches 100 

value  of 31 

Foot  powder  supplied  by  medical  department 83 

Fomites 157 

Fumigation,  formaldehyde 159 

hydrocyanic  gas 151 

for  mosquitoes 146,  238 


G 

Garbage  cans 53 

Gonorrhea 234 

Grease  trap , 60 

16 


242  INDEX 


H 


Health  of  command,  responsibility  for 25 

statistics  an  index  of 153 

Hearing,  test  for 11 

Heart,  soldier's 72 

Hellebore  for  prevention  of  fiy  breeding 55 

Horses,  water  for 43 

Hot  water 67,  88 

Hydrophobia 196 


I 

Incinerator,  improvised 59 

Jones's  improvised 93 

multiple  shelf 52 

railroad  iron 54 

Straub 50 

Influenza    ......             180 

Inspection  form,  sanitary 29 

Inspections,  foot 83 

for  lice 97,  134,  211 

physical 76 

for  scabies 203 

Iron  sulphate  as  a  deodorant 100 

Isolation,  limitations  to 156 

Itch  mites 116 


K 

Kitchen,  care  of 26 

slops 61 

Larvacide 148 

Latrine  boxes 56 

Latrines,  care  of .  58 

for  moving  commands 93 

seating  capacity 59 

in  trenches 98 

Leather  goods,  sterilization  of 135,  203 

Lice 127 

and  typhus     .       .      .      ; 210 

delousing        .      .      ,      , 133, 213 


INDEX  243 

133 

Lice,  dissemination  of .      •      - 

effects  of  heat  on  clothing 

feeding  habits ^oc 

insecticides -oq 

life  cycle ^or 

steam  laundry  in  eradicating 

Lipovaccines -oc 

Lysol  for  destruction  of  lice  • '  ■  88 

Lyster  water  bag 

M 

.      .      ■      •     181 
Malaria g 

MaHngering ^2 

back Q 

cardiac  lesions • „ 

epilepsy ,^ 

hearing ■ ^^ 

urine          ,^ 

vision ^^rj 

Malta  fever p-o 

Manure,  disposal  of ' 

Mattress  itch -^ 

Measles ,^, 

Meat  safe,  improvised 

Meningitis .g 

Milk,  bacterial  count 

grading •  ^^ 

pasteurization 

sanitary  supervision  of 

Mosquitoes „_ 

Anophelina^ 

antimosquito  work  in  cantonments |^^ 

Culex j^^ 

draining ,.„ 

r       •      J--                                                                                                  ...       146 
fumigation 

larvacide _ 

life  cycle ^^^ 

mosquito  bars 

range  of  flight 

screening  material 

Stegomyia 

,,  ^'^^^. :  :  :  190 

Mumps 


244  INDEX 


N 


Naphthaline  for  lice 135,211 

Non-effective  rate 154 

O 

Order,  model  sanitary '24 

Overcrowding 61 

P 

Pappataci  fever - 184 

Patterson's  straddle  trench  cover 94 

Pediculoides  ventricosus .  203 

Pediculus 128 

Phthirus  inguinalis 129 

Physical  training 71 

Picket  lines,  care  of 28,  53 

Pignet's  index  of  efficiency 74 

Plague 192 

vaccine 22 

Pneumonia 185 

pneumococcus  vaccine .             .  22 

Prisoners  of  war Ill 

Prophylactic  treatment,  venereal 77 

Prostitutes,  lice  among 133 

Piamp,  spray 58,  110 

R 

Rabies 196 

Rates,  admission 153 

non-effective 154 

Rat  traps,  use  of 102,  195,  236 

Ration.  U.  S.  Army .  41 

Recreation *    .      .      .      .  69 

Recruits 14 

correction  of  defects  in 7 

vaccination  of 17 

Report,  special  sanitary 30 

Reports  of  epidemic  disease 152 

Roaches 150 

Rock-pile  crematory 49 


INDEX  245 

S 

Salvarsan.     See  Arsphenamine 224 

Sanitary  administration  of  civil  territory 112 

inspection  form 29 

order 24 

Sarcoptes  scabiei 116,  202 

Scabies 202 

Scarlet  fever .  204 

Schick  test 175 

Screening  material 149 

Shoes,  fit  of 79 

Smallpo.x 205 

Socks,  care  of 83 

Soldier's  heart 72 

Sources  and  modes  of  infection        .       .       .     ^ 154 

Space  required  by  soldiers 62 

Statistics  as  an  index  of  sanitation 153 

Stegomyia  as  the  transmitter  of  dengue 171 

Straddle  trenches 94 

Straw  itch 203 

Sulphur  fumigation 146,  150 

Syphilis 221 

scheme  of  treatment 230 

syphilitic  registers 234 

T 

Tents,  ventilation  of 66 

Territory  under  military  control,  sanitation  of 112 

Test  for  carbon  dioxide 64 

Tetanus 207 

Training,  physical 71 

Trap,  fly     ... 125 

grease 60 

rat 102,  195,  236 

Trench  fever 105 

foot 102 

latrine 98 

mouth ,      .      .      .  107 

nephritis 108 

urinal        . 100 

Tuberculosis 208 

Typhoid  fever 214 

Typhus  fever 210 


246  INDEX 


U 


Urinals  in  trenches 100 

Urine  cans,  use  of 27,  58 


V 

Vaccination  by  intracutaneous  puncture 16 

regulations,  cholera 169 

smallpox 14 

typhoid 16 

Vaccine  virus,  to  obtain 206 

Vaccines,  oil 22 

Venereal  diseases 221 

prophylaxis 75 

Ventilation 63 

test  for  carbon  dioxide 64 

Vermijelli,  composition  of 211 

Vision,  test  for 10 

Vitamines 42 


W 

Water,  a  method  of  titration  to  determine  amount  of  chlorine 

necessary  for  sterilization 90 

amount  required  for  horses 43 

bag,  Lyster 88 

boiled 93 

hot 68,88 

on  the  march 85 

method  of  sending  samples 43 

minimum  requirement 43 

purification  in  the  field 88 

in  trenches 100 

waste,  disposal  of 60 

Weil's  disease 235 


Y 

Yellow  fever 237 

Young  Men's  Christian  Association 70 


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